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MEDICAL WASTE TRACKING FORM NUMBER
<br /> 4 ee Stericycle¢ IN CASE OF EMERGENCY CONTACT; CHEMTREC 1 .800424.9300 STANDARD MANIFEST 001 -03.21 -NOCA
<br /> Ronta #. 703 - 16 CUSTOMER N0. 21132 MDTK000DRV
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATA Eric Crowley
<br /> TUItAY DIDIALYSIa-DAVITA 92016
<br /> 312 S FAIRMONTAVE 2122/2022
<br /> LORI , CA 95240- 3840 (209) 369-5418
<br /> I
<br /> CUSTOMER NUMaER 6053303-001 GENERATOR'S REGISTRATION t!
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF 20. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., ) 'iT� 14 -�Pattt) nerate) GSI . Tub ( ON AINER
<br /> 6,21 PGII T8 14 -�BI � TY14 -� inal �t . 9G�uP � , Cu Ft.
<br /> 62t PGII Regulated Medical Waste, n.o.s., T1121 -(Blo ) TP154Path). TY1540hento ) 20 Gal . Tub J Cuft ) Cu Ft
<br /> 0 6U23P9GII Regulated Medical Waste, n.o,s„ Tt349 -(Bio ) TY49-(Chemo) T14941ricinerate ) 37 Gal . Tu (4 . 9 Guft. ) Cu Ft.
<br /> 623P9GII Regulated Medical Waste, n.o.s„ M434nlo) CVA3-(Chemo) WX434Phatm) 43 Gal . Tu (5 .700 .) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s„
<br /> IZ 6.2, PGII KR (81a) Gal . Corrugated Box (4 .32 Cuft .) Cu Ft.
<br /> 60232291 , Regulated Medical Waste, n.o.s,;
<br /> f f .3Cv � . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Ft*
<br /> 6.2, PGII
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.as.,
<br /> 6.21 PGiI Cu Ft.
<br /> 3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS / • Cu Ftm
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are in all respects In proper condition for transport according to applicable International and national governm lel regulations;'
<br /> Print Name SI nature Date
<br /> 4. TRANSPORTER 1 ADDRESS: hone M: (209) 29441114 `
<br /> Staricycle , Inc . This Is a Through ShipmC t Applicable Permit Numbers*
<br /> < 0 7875 R A Btidgerurd Rd . TS/OST 80
<br /> � N Stockton , CA 95206
<br /> SLE a TRANSPORTER CERTIFICATION : Receipt of medical waste as des:rvi
<br /> .
<br /> I 13212 �2Q
<br /> Print/Type Name Cat1 Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #1
<br /> aNr, Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone q:
<br /> Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> a
<br /> � — Prinl/iype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> } 8A. Designated Facility: 8 Alternate Faoltlty: BC. AHemah Facility: 813. Alternate Fecliky:
<br /> #)I SSE ated, ycle , Inc . (Indrisrator) Stericycle , Inc . (Autriclave) Covanta Marlon , Inc
<br /> LL 876 R A , SON Foxboro Drive 2776 E , 26th St, 4060 Urooklake Road NE
<br /> i•- tocktan , CA 943AL A North Salt Lake , UT e4054 Vernon , CA 90058 Brooks , OR 97306
<br /> Z ( 09 ) 2944114 (801 ) 3601171 (856 )783- 7422 (505 )393 -0890
<br /> M $ /OST 80 JAN 2 6 2022 3A•44 /JA- 36 Pi lrrnit # 3"antaMarfonina
<br /> Q 4;150 &ookla5a Rd, W 2aiem, OR 97305
<br /> Lu
<br /> loaners ed
<br /> T EATMENT FACILITY: I certify that I have een authorized by the applicable state agency to accept untreated medical wastes and t�tat I have
<br /> I- re Ned theapo_ .v_e ip In actor nce with the requirement outlined In that authorization , FEB 2 8 202
<br /> Pri pe Name Signature Date
<br /> 5tX X441 o
<br /> frlOMrtn3 63�43�4
<br /> ORIGINAL
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