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MEDICAL WASTE TRACKING FORM NUMBER <br /> ' STANDARD MANIFEST 001.10-06-STD <br /> o:•0 5 i�@1'1C!/CI@' I F SIE cY co cT:CMEMTREC 1-800 A2493n0 <br /> ®�/ er.u.emQr..p.a �y:aa � — CUSTOMER NO.21132 MDI'R00I I E8 <br /> i <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTAi:Iterltz Tabatzgaule:a 1!Il (I <br /> DELTA SIERRA DIALYSIS CENTER <br /> 555 W BEN,7AMI74 B3ALT DR STE 200 <br /> STOMME, CA 95207— 3839 <br /> (209) 473-2294 7/11/2016 <br /> CusTCMEnNUMBER (50-17746-002 GeNERATows REcusTnATioN# <br /> 2A.DRSCRIPTION OF WASTE 2B. CONTAINERTYPE 20. NO.OF 2D. VOLUME <br /> UW291 Regulated Medical Waste,n o s, TBOS — 40 tial Tub (Bio) (5.3 cu ft) CONTAINERS <br /> 6.2,PGI1 Cu Ft <br /> UN3291 Regulated Medical Waste,n.os, T1349 — al Ttab (H o) (4.9 Cil it) <br /> 6.2,PGIi Cu Ft <br /> ON3291 Regulated Medlcai Waste,n o s., 18 — 44 Tulp(Bio) (5.9 CU TV <br /> ® 6.2,PGIj Cu Ft <br /> fi 23PGIi Regulated Medical Waste,n o s., — — — )20 Cu Ft <br /> W UN3291 Regulated Medical Waste,n.os., WB31—(B 0)/WP31—(Bath) 0631—(Chemo}31 Coal T (4.14C ) <br /> IZ 6.2,PGIi Ca Ft. <br /> CD 6 23PGIi Regulated Medical Waste,n.o.s., WB43—(Bio)/PW43—(Path)/ 42—(Chemo) Gal Tub(S.7CUPT) Cu Ft <br /> UN3291 Regulated Medical Waste,n.o.s., MtB — Biosystems Cardboard Box (4.2 cu ft) <br /> 6.2,PGII Cu Ft <br /> UN3291 Regulated Medical Waste,n os. <br /> 6.2,PGI1 Cu Ft <br /> UN3291 Regulated Medical Waste,n o.s, <br /> 6.2,PGIi Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS® Ot R <br /> d9aVrEN above by the proper shipping name,and are classified,packaged,marked and labelled/ carded,and <br /> II Xespects.In proper condition for transport according to applicable international and nation vernmentai regulations" ! rte <br /> P ednyped Names ✓�° j :g 1 Phone# to <br /> a SPORTER 1 A exlcycle, Inc. This is a Through shipment ipment <br /> >° <br /> Applicable Permit Numbers. <br /> 4135 W. Swift Ave <br /> 4R Freano,CA 93722 Seuler Reg# 3400 <br /> m <br /> R z TRANSPORT ERTI IC :Receipt of medical waste as describe abov �J(/� <br /> Printltype Name �l Signature Date 414�1 G sO <br /> 5.INTERMEDIATE HANDLER'2/TRANSPORTER 2 ADDRESS. Phone 9- <br /> a I Applicable Permit Numbers <br /> IR <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pdntif ype Name Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone#: <br /> Applicable Permit Numbers- <br /> Rif <br /> umbers•R f INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, i <br /> — Print/lype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> 8A.Designated Facility. 88.Alternate Facility: ❑8C.Alternate Facility. Ej SD.Alternate Facility: i <br /> d yc Ott Ster1 ®,Inc. (tricycle.Inc. <br /> 4138 W. 90 N.Foxboro DrNe 1661 Shelton DrNe <br /> iQ Fresno,CAd93722 North Sat Lake.UT 64 Holllateir.CA 85023 <br /> (Sela=7 .2 2016 (666)783-7422 (866)783.7422 <br /> Ts/ SA-4494 -3S 7310ST 83 <br /> aTREATMENT FACILITY:I cTritify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> t- received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br /> Printrlype Name Signature Date <br /> s <br /> ORIGINAL <br />