Laserfiche WebLink
--*-- <br /> ® ® MEDICAL WASTE TRACKING FORM NUMBER <br /> O®!®O Ster^'CNCifti' IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-NO424-9300 STANDARD MANIFEST ooi-io os sl D <br /> rmtecun" '2 Rofate#: 046- 5 CUSTOMER NO.21132 MDRC00IIW5 <br /> 1.Generator's Name,Address and Telephone Number <br /> 162111111111111111 <br /> TOKAY DIALYSIS-DAMTA#2616 <br /> i 312 S FAIRMONT AVE 1112712015 <br /> ! LODI,CA 95240-3840 (209)369-5418 <br /> CUSTOMER NUMBER 6053303-001 GENERATOR'S REGtMAnc N# <br /> 2A.DESCRIPTION OF WASTE 2 CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> UN3291 Regulated Medical waste,n.o.s 714-:(E)H )/TP14-(Path)44 Gal Tub(5.9 cu ft) CONTAINERS r ` <br /> 6.2,PG11 ! ( Cu FL <br /> UiE Regulated Medial waste,nos. <br /> T821-(Bio)f TP15-(Path)I TY15-(Cherno)20 Gal Tub(2.7) Cu FL <br /> ® S 2329 Regulated Medical Waste,n.o.s., TB49-(Bio)f TP49-(Path)f TY4&(Chemo)37 Gal Tub(A.8) <br /> Cu Ft. <br /> gUM3291,AegWated Medica}Waste,n a s„ T05-20 Gal Tub(Bio)(3.5 cu ft) Cu Ft <br /> 6 2,PGII <br /> W UN3291 Regulated Medial Waste,n.o s., 64-46 Gal Tub Bt3.4 io)( fit fit) <br /> Z 6.2,PGii -8 ( Cu Ft <br /> s 2.PQ Regulated Medial waste,n.os., WB31-(B1o)f Vi/PM-(Path)i WC31-(Chemo)31 Gal Tub(4.14 cit ft) <br /> Cu Ft <br /> 66A PPGii Regulated Medical waste,R o s., WB43-(Bio)!PW43-(Patti)I CW43-(Chemo)43 Gal Tub(5.7 cu ft) <br /> UN3291,Regulated tuledlat Waste, KRB,,,,---Bits stems Cardboard Box 4.2 cu fit) <br /> 6.2,t'Gq `'Y ( Cu Ft. <br /> Qj Ft <br /> 3,Generator's Certification:"d hereby declare that the contents of this consignment are fully and accurately v Cu FL <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are in ail respects In proper cpqd1borillor.transport accor ingAo appitcele ntemational and national govern ental r Matto <br /> {^ 112rinted/Typed Name Signature f�( ° Date <br /> 4,TRANSPORTER 1 ADDRE one#: (866)783-7422 <br /> w Stericycle,Inc. ® This is 9 ThroUgh Shipment Applicable Permit Numbers- <br /> 11875 White Rock Rd 3400 <br /> 20. Rancho Cordova,CA 95742 <br /> ME <br /> TRANSPORTER CERTIFICATION:Remipt of medical waste aso <br /> PrinKrypa Name`!;t- DA Signatu Date V <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#. <br /> NS� Applicable Permit Numbers <br /> �o <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printftype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#. <br /> icApplicable Permit Numbers- <br /> 0 <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descnbed ova <br /> Printffype Name - Signature Date <br /> 7.DISCREPANCY INDICATION TransfL-rredl!—&:containers.'Oi"t-"--'I cu ft to' Yuba Ci A or Fresno, CA <br /> ❑ Transferred containers, cu 6 to: North Salt Lake, UI"or Fresno, CA <br /> aA Deatgnatad Facility. as Aitemata Fecinty: eC.Alternate Facility: 6D.Alternate Facility: <br /> titsyde, Inc. Stericycle, Inc. Stericycle, Inc. Stericycle, Inc. <br /> 10 <br /> 1612 Starr Dr. 90 N. Foxboro Drive 4135 W. Swift Ave 9551 Shelton Drive <br /> lLL <br /> . , Yuba City, CA 95993 North Salt Lake, Ur 84054 Fresno,CA 83722 Hollister, CA 95023 <br /> (91 (901)836-1171 (910)985-55506 (866)783-7422 <br /> TS/ 3A448/JA 38 TS10ST 22 TSIOST 83 <br /> U9 I ttjDgrtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> F Fie t .uvastes in accordance with the requirement outlined in that authorization. <br /> Prin Signature Date <br /> . 1 <br /> ORIGINAL <br />