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10/25/2010 14:34 FAX 2098390799 Q0008/0009 <br /> 10/15/2010 17:01 Remote ID int ID D 4/5 <br /> MEDICAL WASTE TRACKING FORM NU 8C2 <br /> 0 S - IN CASE OF EMERGENCY CONTACT:CHEWrRac i-wo- -rD t STANDARD MANIFEST oot-io-os <br /> •' Route #. 809 -16 MDSNOOHOV8 <br /> 1.GeriemWs Nae,Address Tele Number <br /> } <br /> DAVITA f) , <br /> 425 BEVERLY ST $TE A <br /> TRACY, CA 95376 <br /> (209) 839-0398 10/12/2009 <br /> IaNumBER 6018152-005 REGOrRMOINs <br /> 2A.DESCWTION OF WASTE 28, C 0 W-A M E RTYPE 2C.NO.OF 20. VOLUME <br /> REGULATED MEDICAL WASTE,n os..6 C014T ERS <br /> UN 3291,PG II 57 - 40 ®ail (Llio) (3<2 cu !t) cup <br /> REGULATED MEDICAL WASTE,n.os.,62, T814 - 44 Gal Tub thio), CT 12.7 11) (5.9 cu it! <br /> UN 3291.PG 11 Cu F <br /> REGULATI?DMEDICAL WASTE,n.os.,6.2, 8921 - 20 Gal 'Pub (Bio) (2.7 a-,u tt) <br /> Q UN 3291•PG 11 Cu F <br /> Q REGULATED MEDICAL WASTE,n os.,62, T849 - JT Gal T (rs i.o), 10.7M (41.9 r_.0 it) <br /> cc UN 3291,PS II Qu F1 <br /> W =5TEDMINFALWA "bs.,6.2- T615 - 20 Oa3. Tub (Patut) (2.7 Cu rt) Cu PZZ UN 3291,PG II <br /> Q <br /> REGULATED MDICALW nos„62, TTt15 - 20 Gal Tub (GheMo) (2.7 cu it-) <br /> UN 3291,PG It <br /> Fi <br /> REGULATED MEDICAL WASTE.nzs.,62, TB35 - 26 Qat Tub (Bio) (3.3 Cu tt) <br /> UN 3291,PG It Fi <br /> REGULATED MEDICAL WASTE,mos..62, <br /> UN 3291 PG If gg El <br /> gg®� A <br /> 3.Generator's Certification:"I hereby dedwe that the contents of this consignment we fully and nomm Ta ry ® Cu FI <br /> descrbed shoos by the proper shipping name,and are classified,packaged.marked and laared <br /> are inti all respects in proper condition for aoconfiing to applicable' and national governmental r <br /> Ae tPfin Name SRN v ra Date <br /> t; 4.TRANSPORTER 1 ADDRESS: Phone d: l U J Ob.4 - t <br /> UI 5teticycle Inc <br /> ApPlicable Permit Numbers: <br /> 1-C 1366-DOOLITTLE DR <br /> _a 9A>!! LE.=aNDRO.CA 995'77 This is b Z9>X.0%1911 S!a i(►tnetr t <br /> �q <br /> TRANSPORTER C FICA as deuxibed <br /> IFZtllrPri Name \ C7 •Sfpraature Date Jb <br /> 5 <br /> iNTEFMAEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone N: <br /> Stericycle, inc 1345 Doolittle C San Leandro, CA 94577 ApplicablePermit Numbers: <br /> IN'TERMEDIATE HANDLER/TRANSPORTER CATION: Receipt of modicei waste as described above. <br /> Printfrype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3!TRANSPORTER 3ADDRESS: Phone a: <br /> w wApplikable Parmil Numbers: <br /> �cc MEDIA HANDL /TRANSPORTER CE CATION: Receipt of mewcai waste as dw=bw awve. <br /> z <br /> Print/rype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Trwoferred cardalnem. Let►K to , North Salt lake,UT <br /> M 88.A ftca”: 8C.A fest FadifI : ®�.Rta iacimy <br /> .11=AUt0dM Stelityde,Inc ,Im,Autoldm Stsricyde,Inc.Indner3bon <br /> v 1 M 00e D ,Su C 3140 N ltl1 St TtYYy 4132 W.GvM.Avenue 80 North i 100 V*St <br /> LL oAe, 7 k Cif.KC 66715 Presto.CA 93M HoAih Sat Lake City.UT <br /> CC 10)062-1761 (91 321 - IS54 559 273- <br /> � ( ) 180111936-1555 <br /> 5 T331.MOST25 EPA* KS0062892612 Class V Incineration P-6,P.115 <br /> Pe 91-02 <br /> TREA ENT FACIL - a4 I have been authorized by the applicable state ager accept untreated medical wastes and that I have <br /> received the icated es in accordance with the requi in nation. <br /> Prira!lfype Name R <br /> OCT 12 2009 <br /> c MEDICAL15 WAST-El <br /> �� G 113061446114881d 05-CM. <br />