Laserfiche WebLink
10/25/2010 14:34 FAX 2098390799 Q0009/0009 <br /> 10/15/2010 17:01 Remote ID _ ID D 5/5 <br /> • A 46 —---—- --- <br /> MEDICAL WASTE TRACKING FORM NUMBEI <br /> SteriicycW IN CASE OF EMERGENCY CONTACT:C"EMTREC 1-000-234-0061 STANDMID MAMFIRST 001-110-011-STO <br /> Route 0; 809 16 MDON000501 <br /> 1.Gen"oes Name,Address and Te one Number <br /> DAVITA JATW: Camon I WIN I I III I 11 <br /> 425 BEVXFtLY ST STZ A <br /> TRACY, CA 95376 <br /> (209) 839-0390 10/5/2009 <br /> Cusrowery Nuareem 6018152-005 GwEm <br /> 2A.DESCRWMN OF WASTE— 213. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> REGULATED MEDICAL WASTE.cto.r,6.2, CONTAINERS <br /> UN 3291.PG 11 9857 - 90 S&L rub (9:1.0 (12 crA ft) Cu <br /> REGULATED MEDICAL WASTE,viox.,6.2. T014 - 44 Gal Tub(Dio), CT LZ.7 lb (5.9 CU tt) <br /> LIN 3291.PG 11 Cu <br /> REGULATED MEDICAL WASTE,—oL",6.Z <br /> UN 3291.PG 11 T021 - 20 "1 Tub (Bio) Cu ft) Cu <br /> REGULATED MEDICAL WASTE,iLos..&Z—!M 4 37 Gal Tub (81o), 10.7 18 (4.9 cu tit) <br /> W UN 3291,PS 11 Cu F <br /> LU REGULATED MEDICAL WASTE.no.sS.Z <br /> Z UN 3291.PIS 11 7915 ZO Gal Tub (Path) (2.7 cu tt) Cu <br /> REGULATED MEDICAL WASTE,—no.&.5.7_ <br /> UN 3291,PG 11 TyiS 20 Gal Tub (Chino) (2.7 cu ft) CU F <br /> REGULATED MEDICAL WASTE,o.o,&,6.2, <br /> UN 3291.PG 11 T83S 26 Gal Tub (Bio) (3.5 cu tV Cu F <br /> REGULATED MEDICAL WASTE,n.o.&.62. <br /> UN 3291.PG 11 -5w4pa 14.f Cu F <br /> Lk rg_u F <br /> 3.tae CartificatIon:"I hereby declare that the contents of this consignment are fully and accurately TOTA10-1 C <br /> LS 'u <br /> described above by the proper~ng name,and are clasaffied,packaged,rnarked and fabolleolecarded.and <br /> are to all respects in limper ndition for transport accordkV to applicable international and national govervirnentaJI requiatons: <br /> V7 <br /> nntedirlyped Name signature lgcreku - —Date <br /> 4.TFIANSPORTER I ADDRESS: Phone#.* <br /> Stericycle Inc Applicable Pennit Numbers: <br /> 1366-DOOL17TLE DR Irmel This is a Through Shipment <br /> SAN LWIFDRO,CA 94577 LN <br /> U) <br /> CE51TIFICA TION: Reow at medical waste as describetv", <br /> cc . A. <br /> Print/Type Nar" v le'A"N "nwi:; Signab" Date /dk <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#: <br /> Steri le, inc 1345 Doolittle C San Leandro, CA 94577 Applicable permit Numbanx <br /> WTERMEDIATE HANDLER/TRANSPORTER CFERTIFICAMON: Receipt ol madkal waste as descfibed above. <br /> Pdntfrype Naffm Signature Doe <br /> 6.INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS: Phone 0. <br /> a 4 cc Applicable Pernik Numbers: <br /> um <br /> INTERMEDIATE HANDLJER/TRANSPORTIER CERTIFICATION:Receipt of medical waste as described above. <br /> Pr!nVrype N&M Signature Date <br /> 7.DISCREPANCY INDICATION <br /> Tmnsimd I_oWalnem, CP CU It to: MOM$aft lake,UT <br /> rim GA.DwWmftd Facility. SIL Affornala FeMr. E]8C.Aftmaft Facility- 8MAliternalaRecill1r. <br /> xy s v <br /> B *g%30&g&U <br /> NW Stericycle,Inc.Inc1nerdon <br /> SbirWyde.Inc. SWkyCle,1Ar-AIIAWWO <br /> C 3149 N Ah M TfWY 4 f 22 W.G*Aft Aventm 50 NofM 1100 Wast <br /> 0616 " <br /> eftn LAX=ndm WAWU%ftft0HV-WQ 09418 Preene.QA 93722 North tolk Lake efty.Ur 64ag <br /> AX&Q" <br /> k5m) 1781 (923)321 -1 (552)275-032111 (1 )W16-1555 <br /> 7331,TSIOST25 EPA* KSM2892612 Ck=V IndnersUon P-6,P-1 is <br /> Pe 91-02 <br /> U <br /> TREATMENT FACXJW: rtibAa!I have been authorized by the applicable a age accept untreated mescal wastes and that I have <br /> Imo- received thea ed <br /> I eed in accordance with the requirement in th tion. OCT 0 5 2009 <br /> PrIntrWe Name ev vv _Signature Date <br /> 14 7 <br /> ORIGINAL OftMarA14881d MOW= <br />