|
MW MEDICAL WASTE TRACKING FORM NUMBER
<br /> Q
<br /> 0•0 Stericycle* IN CASE OOFIJAE!FENCU81�TIF.CHEMTREC 1-800-424-9300 00MAN6 -10-06-STO
<br /> R e fee j f 001
<br /> h IND 7
<br /> CUSTOMER NO.21132
<br /> 1.Generator's Name,Address and Telephone Number
<br /> ATTN-.Efic Crovdey
<br /> TOKAY DIALYSIS-DAVITA#2016 11111111111 IN milli 1111111111
<br /> 312 S FAIRMONT AVE 411512016
<br /> LODI,CA 95240-3840 (209)369-5418
<br /> Cus-romm NUMBEF; 6053303-001 GENEFimaws RIEGISTRAMON#
<br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 20. NO.OF 2D. VOLUME
<br /> ON3291
<br /> 6.2. ,,,Regulated Medical Waste,ri.os., IBI�4.(Slo I TP14-(Path)44 Gal Tub(5.113 cu ft) CONTAINERS Cu Ft
<br /> UN3291 Regulated Medical Waste,n.0-s-, TB21-(Rio)/TP1 5-(Path)/TY15-(Chemo)20 Gal Tub(2.7)
<br /> 62,FG11 Cu Ft
<br /> jr UN3291,Regulated Medical Waste,MO.G., TB4@-(ffio)/TP49-(Path)/TM-(Ch! 37 Gal Tub(4.9)
<br /> 61211131311 Cu Ft
<br /> UN3291 Regulated Medical Waste,n.o.r, al I Lit;LIMU)
<br /> 6.2,FGH Cu Ft.
<br /> Z
<br /> Ul UN3291,
<br /> PGII Regulated MedlWwOste,n 0.8. T884-48 Gal Tub(Bio)(13.4 cu it)
<br /> 6.2. cu R
<br /> Uj gl -(Bio) -(Path)/WC31-(Chemo)31 Gal Tub(4.14 cu ft)
<br /> ,!211,,Regulated Medical Waste,A O.S.,
<br /> 0 pe VV831 io)/WP31 Cu F16
<br /> UN3291 Regulated Medical Waste,A-03., WB43-(81o)I FW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft)
<br /> 62,P61i Cu R
<br /> UN3291.Regulated Medical Waste,n.o--,, MEL_-Biosystems Cardboard Box(4.2 cu ft)
<br /> 62,PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste,n.oA,
<br /> 6.2.PGII Cu Ft
<br /> 3.Generator's Certification.11 hereby declare that the contents of this consignment are fully and accurately IIH Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and
<br /> are in all respects In proper Wndition for transport amriding to applicable Intemational and national govern ental regu
<br /> Signature 710' _i ?1jY1,4A1
<br /> 'X PLn�adaypld Me IRUW V1W A . M, i 0 - . t - -
<br /> 4.TRANSgRTPR 1 e,
<br /> D13ESS- V Phone if (Ubb) IlRi-14ZZ
<br /> ancyc e e,Inc. This is a Through Shipment Applicable Permit Numbs
<br /> 11875 Whide Rock Rd '3400
<br /> 0
<br /> 0. Rancho Cordova,CA 95742
<br /> 9L a TRANSPOONR CERTIFICATION:Receipt of medical waste ascn
<br /> I
<br /> cr.
<br /> Prinvrype Nam Signet D 4.
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone
<br /> Applicable Permit Numbers.
<br /> C11 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> IPrIntflype Name Signature Date
<br /> V3 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone#
<br /> Applicable Permit Numbers
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrInit"a Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> IQ M Designated Facility., 08.Alternate Factuty; W_Alternate Faculty. 80.Alternate Facility.
<br /> Maricycle, Inc. Stericycle, Inc. Stericycle. Inc.
<br /> 4f 4612 Stem Dr. 90 N. Foxboro Drive 4135W. SvARAve
<br /> U- Yuba City, CA 95992 North Sat Lake, LIT 94054 Fresno, CA 93722
<br /> (520)766-0595 (801)936-1171 (630)755-GS85
<br /> TS/0ST 80 3A-4481JA-36 TWOST 22
<br /> 04
<br /> TREA il have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> race Vjjo
<br /> Z14 accordance with the requirement outlined In that authoriz
<br /> PrinNFype Na ..
<br /> Signature Date
<br /> Transferred containers—._Z12L.—4— CU it to,-Cyj&a city,
<br /> CA or sno, CA
<br /> -ransferred containers. cu ft to or Frey, CA
<br /> ORIGINAL
<br />
|