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MEDICAL WASTE TRACKING FORM NUMBER <br /> 0"�* StericycIV IN CASE OF EMERGENCY CONTACT.CHEMTREC I-BOD-424-MOO STANDARD MANIFEST 001-10-06-SM <br /> •0 Route#. 036- 2 CUSTOMER NO.21132 MDRCBUJBYI <br /> 1.Generator's Name,Address and Telephone Number jj <br /> ATTKI:Ede Crovdey <br /> TOKAY DIALYSIS-DAVITA=16 IlI <br /> 312 S FAIRMONT AVE 412212016 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> CUSTOMER NUMBER 6053303-001 GENERATOR'S REGISTIPIATION# <br /> 2A.DESCRIPTION OF WASTE 20- CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UN3291 <br /> CONT ERS <br /> 6.2. ,,Regulated Medical Waste,n-(S-' f TP14-(Path)44 Gal Tub(6.9 cu it) Cu Ft. <br /> UN3291 Regulated Medical Wast®,nos.,6.2.PGII T821-(Blo)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2.7) Cu Ft <br /> CC UN3291,Regulated Medical Waste,n.o.s.1 <br /> 6.2,PGII: , TB49-(Bio)I TP49-(Path)/TY49-(Chema)37 Gal Tub(4.9) Cu Ft <br /> UN3291 Regulated Medical Waste,n <br /> OR poll 'O's' T886-26 Gat Tub(81o)(3.5 cu ft) Cu FL. <br /> CC <br /> LU UN3291 Regulated Medical Waste,n.os., <br /> Z GA Pell TE364-48 Gal Tub(Sic)(6.4 cu ft) Cu FL <br /> Uj <br /> UNS291 Regulated Medical Waste,mox., <br /> 6.2.PGI W831-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 cu ft) Cu Ft <br /> UN3291 Regulated Medical Waste,n.os.. <br /> 6.2.FGH WB43-(Bio)/PW43-(Path)I CW43-(Chemo)43 Oaf Tub(5.7 cu ft) Cu Ft <br /> UN3291,Regulated Medical Waste,ri.o.s., <br /> 6.2,PGII KRB—-Bi osysterns Cardboard Box(4.2 cu ft) Cu Ft. <br /> UN3291 I Regulated Medical <br /> 6.2.PGII Cu Ft <br /> 33.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 10- Ft <br /> . <br /> described above by the proper shipping name,and are classified,packaged,marked and labelledtplacarded,and <br /> are In all respects in proper condition for transport according to applicable Interriabonall and national governmental 0 <br /> XPrInted%pad Name Lb�a�fz Clng:' Signature, �—DateO't]A&114 <br /> 4.TRANSPORTER I ADDRESS: Phone n- (866)783-7422 <br /> Stericycle,Inc. This is a Through Shipment Appilaable Permit Numbers: <br /> I 10875 Mile Rack Rd 34013 <br /> 90 <br /> a. <br /> ME M Rancho Cordova,CA 95742 <br /> TRANSPO i R CERTIFICATION:Receipt of medical waste as son <br /> TI IM <br /> -�—Z -A Signatus at <br /> PdriMpaNai 5�1�t: g:j— !::� I <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone <br /> Applicable PenTut Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrInt/Type Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone 0. <br /> Applicable Permit Numbers. <br /> 102M <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> X <br /> SA n SC,Aftemate Facility. 8D.Aftemate Facility. <br /> 13.Aftemate Facility. <br /> berDesignated Facility: 8icyc1e, Inc. Slericycle.Inc. Stericycle, Inc. <br /> oil 9692 Starr Dr. 90 N. Foxboro Drive 4135 W. SW It Ave <br /> 4 <br /> U, <br /> t, R Yuba City, CA 96993 Nodh Saft Lake,UT 84054 Fresno, CA 93722 <br /> U1 (530)755-05135 (801)938-1171 (530)755-05e5 <br /> TS/OST 80 3A-448/JA-36 TWOST 22 <br /> TREATffMj Ve been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> receive -US cordance with the requirement outlined in that authorization. <br /> ,Print/type Name Signature Data <br /> d= <br /> ren <br /> Aar Fresno, CA <br /> containers,I 0!�•- <br /> Transferred -CU ft td'� A <br /> Tran <br /> ­&� containers, Cu ft or Fresno <br /> Tr=ansferred CA <br /> ORIGINAL <br />