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MEDICAL WASTE TRACKING FORM NUMBER
<br /> ere* 0
<br /> Stericycle- INCASIWFYEPENC C,0,!TAgMCHEMTREC1-800-424-9300 STANDARD MANIFEST 001-10-WSM
<br /> • NOW""%Q%ft ft: e . 64 CUSTOMER NO.21132 MDRC00IJW5
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN:Cheryl
<br /> TOKAY DIALYSIS-DAVITA#2016
<br /> 312 S FAIRMONT AVE 12/412015
<br /> LODI,CA 95240-3840 (209)369-5418
<br /> 5
<br /> CUSMMER NUMBER 603303-001 GENanmows REGwnAnoN#
<br /> 2A.DESCRIPTION OF WASTE CONTAINERTYPE 20.NO.OF 2D. VOLUME
<br /> P CONTAINERS
<br /> Y'rM 8'�o
<br /> UN3291 Regulated Medical Waste,rms( T814-(8i /TP14-(Path)44GalTub(5.9cuit) q '%-�L,L Cu Ft
<br /> 6.2.Pell
<br /> 1162,Gil �'�-(�gia)/TPIB-(Palh)/TY15-(Chemo)20 Gal Tub(2.7)
<br /> N3281 Regulated Medical Waste,n.os., Cu FL
<br /> Cr. UN
<br /> 8291 Regulated Medical Waste,n.os, TB49-(Bio)I TP49-(Path)/TY4G-(Chemo)37 Gal Tub(4.13)
<br /> 0 6.2.PGII Cu Ft.
<br /> UN3201 Regulated Medical Waste,n.o a.,
<br /> kz poll T836-28 Gal Tub(Sic)(3.5 cu ft) Cu Ft.
<br /> UN3201 Regulated Medical Waste,n.o s,
<br /> Z 6.2,PGI l TBB4-49 Gal Tub(81o)(18.4 cu ft) cu Ft.
<br /> uj
<br /> 0 32010gulated Medical Waste,ii.o.s.,
<br /> 6 2,
<br /> A VM31-(Eric)/\AIP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 cu ft) Cu Ft.
<br /> N
<br /> U3201
<br /> 6.2,P,,,Regulated Medical Waste,n.c.s., \A1643-(8io)/PW43-(Path)I CW43-(Chemo)43 Gal Tub(5.7 os ft) Cu FL
<br /> 62UN3201 Regulated Medical Waste,ii.as., KRE� Biosystems Cardboard Box(4.2 cu ft)
<br /> ,PGIl Cu Ft.
<br /> Cu Ft
<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately LS 11lo- Cu FL
<br /> described above by the proper shipping name,and are classili .packaged,marked and labelled/placarded,and
<br /> are In all respects In proper condition for I rt according pplicable International and national governmental regulations"
<br /> i eeel' L;ttW-1- ;all//5 I
<br /> 'XiPrinted%ped Name —Signature —Date
<br /> OC
<br /> 4.TRANSPORTER I ADDRESS:V- Phone#:(866)783-7422
<br /> Stericycle,Inc. 7 1
<br /> N] This is a Through Shipment Applicable Permit Numbers
<br /> 0 11875 White Rock Rd 3400
<br /> a. Rancho Cotdova,CA 95742
<br /> TRANSPO CERTIFICATION:Receipt of medical waste as d ova
<br /> Prinm-"Nam® SignatureDate
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone
<br /> Applicable Permit Numbers:
<br /> oo
<br /> rZ INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> qype Name Signature Date
<br /> ,?;IF,R CERTIFICATION:Receipt I
<br /> 6.INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS: Phone
<br /> 21 cc Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above,
<br /> PrInt/Type Name Signature — =h Date
<br /> 7.DISCREPANCY INDICATION Transferred La containers, cu ft ta�'.-Yuha--Cit , Q-A-i,or Fresno, CA
<br /> ❑ y
<br /> Transferred containers, ou ft to: North Salt Lake, UT or Fresno. CA
<br /> Designated racillir. n8B.Alternate Facility. ---- ❑8C.Alternate Facility- E]BD.Alternate Facility:
<br /> SUricycle,Inc. Stericycle,Inc. Stericycle. Inc. Sbericycle,Inc.
<br /> 1012Starr Dr. 130.,N,. Foxboro Drive 4136 W.SVVlft Ave 1551 Shelton Drive
<br /> Yuba City.CA 95993 Nbl�ffpalt Lake, UT 84054 Fresno, CA 93722 Hollister, CA 95023
<br /> (916)985-5506 (817'1);1;33&1171 (81e)086-5500 (868) 783-7422
<br /> TS/OST 80 TRATWED 3AA48/JA-86 TS/OST 22 TWOST 83
<br /> ccLu TREATME been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> I
<br /> I- received It nce with the requirement outlined In that authorization.
<br /> Printn)pe Name Signature Date
<br /> ee
<br /> L-. .�
<br /> 01
<br /> ORIGINAL
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