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0• MEDICAL WASTE TRACKING FORM NUMBER <br /> -06- <br /> **p Stericycle* IN CASE OF EMERGENCY CONTACT*CKEMTREC 1-800-424-MOO STANDARD MANIFEST 001-f0 STD <br /> " PMeW.pft*&RtdWJnjjRW Route* 046- 5 CUSTOMER NO.21132 MDRCOUJ41F <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTR:Ede Crovdey all <br /> TOKAY DIALYSIS-DAVITA#20`16ill li lilii 11 li #1 ! #� it #11111 1 111 11111 <br /> 312 S FAIRMONT AVE 31251201 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> CUSWMER NUMBER 6053303-001 GENERATOR'S REGISTRAMON# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 2D. VOLgU�� <br /> UN3291 Regulated Medical Waste,n,osfj1:4-&I /TP14-(Path)44 Gal Tub(5.0 cu It) Cu CONTAINER <br /> 6Z PG)i Ft <br /> UN - <br /> 3291,Regulated Medical IM II.O.S., <br /> 6.2,Nil T1321-(Bio)/TP1 6-(Path)/TY1 6-(Chemo)20 Gal Tub(2.7) Cu Ft. <br /> CC UN3291,Regulated Medical Waste,n,o.s., <br /> 6 2.PGII T134G-(Bio)/TP49-(Path)/TY49-(Chemo)37 Gal Tub(4.9) Cu Ft. <br /> !OR UN3291 Regulated Medical Wads,n.o.q, <br /> X 6A PGII TE335-20 Gal Tub(Bio)(3-5 cu ft) Cu Ft. <br /> W UN3291,Regulated Medical-Waste,11,01, <br /> Z 6.2,1`011 TE364-48 Gal Tub(810)(8A cu ft <br /> UN2391 Regulated Medical Waste,n.O.S., <br /> 6.2,PGII W1331-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 o ft) Cu Ft <br /> UN3291,Regulated Medical Waste,nx,s, <br /> 6.Z PGII W13 -(Bio)I PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft) Cu Ft <br /> UN3291 Regulated Medical Waste,n'o's' KRB„_-Biosystems Cardboard Box(4.2 ou ft) Cu FL <br /> 62UN329tPGII Regulated Medical Waste,n.os..! <br /> , <br /> Cu R. <br /> 3.Generator's Certification:01 hereby declare that the contents of this consignment are fully and accurately TOTALS 1110- CU Ft. <br /> described above by the proper shipping namej and are classified,packaged,marked and labelled(placardad-and <br /> are In-all respects In proper condition fo transport acoording to applicable international and national governing tail regulations' <br /> XPrInted%ped Name Sig!4 re <br /> 4.TRANSPORTER I ADDRESS: Phone (866)783-7422 <br /> Stericycle,Inc. Q This is a Through Shipment Applicable Permit Numbers, <br /> 11875 White Rock Rd 3400 <br /> Rancho Cordova,CA 95742 <br /> Z <br /> < TRANSPO IT--R CERTIFICATION:Receipt of medical waste as <br /> PdntMMpe Nam 5 Signstutr' M�Q Da <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2ADDRESS: Phone <br /> Applicable Permit Numbers, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> PrIntrrype Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3 ITRANSPORTER 3 ADDRESS Phone# <br /> Applicable Permit Numbers. <br /> 101 aa. INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> I <br /> Pdngfte Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> M Designated Facility: es.Aiternate raciatr. se.Attemate Facniv. E]So.Alternate Facility. <br /> tericycle. Inc. <br /> Stericycle. Inc. Stericycle,Inc. Stericycle, Inc. <br /> 1012 Starr Dr. 90 N.Foxboro Drive 4135 W. SM&Ave 1551 Shelton Drive <br /> Yuba City, CA 95993 North Sat Lake, Ur 84054 Fresno,CA 93722 Hollister, CA 95023 <br /> (946)986-6606 (801)936-1171 (99e)1385-5506 (888)783-7422 <br /> MOST So 3AA481JA-36 TS/OST 22 TS/OST 83 <br /> TR EJAV"-ME ve been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> T ve <br /> r We V <br /> 4 Z .ardance with the requirement outlined in that authorizaticn <br /> affl-A".. 04 0.Ij <br /> Pnnt/l NameSignature Date <br /> 0> <br /> /* Transferred I containers,' cu ft to 4: VJba�Cfty, CA r Fresno. CA <br /> rre <br /> d—containers, cu It to : North Salt Lake, LIT or Fresno. CA <br /> ORIGINAL <br />