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MEDICAL WASTE GENERATOR <br /> FILE COVER SHEET <br /> FACILITY ID#: FA0010846 P/E: 4530 DATE: 01/07/2009 <br /> PROGRAM RECORD#: PR0522690 P/E: DATE: <br /> P/E: DATE: <br /> i <br /> DDRESS: 425 W BEVERLY PL A CITY: TRACY <br /> ACILITY NAME (DBA): DAVITA TRACY DIALYSIS y <br /> FACILITY PHONE: (209) 839-0398 FACILITY FAX: <br /> FACILITY CONTACT: LICENSURE & CERTIFICATION DEPT PHONE: <br /> OWNER NAME: DAVITA INC CITY: TACOMA <br /> OWNER ADDRESS: 1423 PACIFIC AVE PHONE: (800) 477-1916 <br /> Water Service: ❑ Large PWS ❑ Small PWS ❑ Domestic Well <br /> Sewer Service: ❑ Public Sewer ❑ OnSite WWTX ❑ OnSite Septic System <br /> Stormwater: ❑ Street Drains ❑ Street Ditches ❑ OnSite Ponds ❑ Other <br /> oaNv Courtney Vela <br /> ta Facility Administrator <br /> I Kidney Care <br /> Tracy Dialysis <br /> 425 W.Beverly Place <br /> Suite A <br /> Tracy,CA 95,376 <br /> Tel:+1(209)839-0398 <br /> Fax:+1(209)839-0799 <br /> Davita.com Cell:+1(682)239-7879 <br /> Courtney.Vela@davita.com <br /> FH 00 18 rev 05/2007 ------ ` - <br /> rpt#: MWCS ._w Owner: Create a New Cover Sheet/Change Label of File <br />