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10/25/2010 14:33 FAX 2098390799 Q0003/0009 <br /> 10/35/2010 16:50 Remote ID __int ID __ p 3/3 <br /> ■ MEDICAL WASTE TRACKING FORM NUMBEF <br /> ®® S Mu eE F Efw2tcy yoffrACT:c" C 1.88o-234.851 STANDARD MANIFEST Wt-10-05-SD <br /> 6 <br /> KDFR00969V <br /> 1.Generator's NaAme,Address <br /> andlTelephone Number I <br /> DAVITA <br /> 42.5 MVEIMY ST STE A <br /> TRACY, CA 95376 <br /> (209) 839-0398 4/27/2010 <br /> CUST101MER NUMBER 6018152-005 Q ®WsRE . o <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 2C. NO.OF 20, VOLUME <br /> REGULATED MEDICAL WASTE.n.os..62. TR57 - 90 Gal Tub (bio) (12 au Et) CONTAINERS <br /> UN 3291.PG 11 OuF <br /> REGULATED MEDICAL WASTE,nos..82. - ® CSF <br /> UN 3291.PG U <br /> CC REGULATED MEDICAL WASTE,n.o4_6.ZT"14 J24 <br /> 0 UN 3291,PGIII J3 . cu <br /> Q REGULATED WASTE.n.o.s.,62. <br /> fZ UN 3291.PG 11 Cu P <br /> W REGULAIM MEDICAL WASTE.rws.,6.2, Tr%1!5----= 6 a Ca <br /> W <br /> UN 3291,PG 11 - CU <br /> 'V R UMT—W M W—AW,n.os..82. TY15 - 20 Gal Tab (Chino) (2-7 cu ft) <br /> UN 3291,PG 11 Cu Ft <br /> REGULATED WEDICAI.WASTE,n.os..62, <br /> UN 9291.PG 11 Cu Fl <br /> REGULATE®MEDICAL WASTE,n.os..6,2, <br /> UN 3291.FG 11 /'� / Cu FI <br /> L?ha acautical Waste )Z /2 (.i'`IAJCHI f•(a Cu ��. !- <br /> a <br /> 3. ors Certlfieatlon:•I hereby declare that the contents of 8tis are fully and aau ralely TOTAL A) <br /> d by the proper sh ng name,and are classified and label ed/placarded,and Fl <br /> in in proper condition far transport accoreft to applicable international and nna5figcsLam&LmmerftI regulations.' <br /> > ' <br /> P ted/T Name I®®�l�t ES 1 inature Oate <br /> 4 RTERr1S: hone#: - <br /> cycle, Inc.IAC. <br /> r 9135 heat Swift Ave. Applleebla Pwm6t Numbers: <br /> aThis is a Through Shipment <br /> F no,CB 93722 <br /> TRANSPORTER ATION:Receipt of medical waNe as described <br /> ~ PrinVWe Name K- Signature Date A,;l <br /> //D <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#: <br /> a1i 6'r Applicabb Permit Numbers: <br /> INTERMEDIATE /TRANSPORTER CERTIFICATION;Rec*t of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 6,INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#: <br /> 5 Applicable Permit Numbers:13 <br /> INTERMEDIATE HAN R/TRANSPORTER FICATION:Receipt of medical waste as described <br /> Prin"pe Name S�nature Date <br /> 7.DISCREPANCY INDICATION <br /> Tra , cu A to: North Saft LAe,UT <br /> Faeility: SM Afterineft Facift ❑BC Agnate Fo011y: W.Allarrals FacOW. <br /> J <br /> sisPicycLi INC CYCLE INC STERICYCLE INC CYCLE INC <br /> 4136 W. FT AVE 90 NORTH I I00 VM59T 9053 NORMS AVE. 2775 E 26TH S11REET <br /> a FRESNO,CA 93722 NORTH SALT LAKE CITY.UT SUN VALLEY,CA 91352 VERNON.CA 0023 <br /> U, (659)276.MW IMI)gn+1655 (810)60.9921`7 t9 s MM <br /> I. V Irdnenilifim Parmilt 91 ,1-110 <br /> 7 <br /> F JACQUI <br /> TREATMENTFACILITY:I certify chat 1 have been auetoriaed by ®app l to accept untreated medical wastes and that P have <br /> Ix received the above indicated wastes in accordance with the requ�im <br /> reent outlined in that authorization. <br /> ir <br /> Print/Type Name Signature,'fA1v- 1_ ?I�1 Date <br /> -201® OFLIGMAL <br />