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^^ MEDICAL WASTE TRACKING FORM NUMBER <br /> ®® • STANDARD MANIFEST 001-10.06-STD <br /> Ster'cyde <br /> O c/p <br /> IN CASE OF EMERGENCY CONTACT.CHEtViTREC 1-Bg0-424-9300 <br /> ®° ro��r.@pl.a mwaaw Route#: 036- 6 CUSTOMER NO.21132 MDRC00JA8J <br /> 4.Generator's <br /> E dAddress and 7elephone Number <br /> �' c CrOvWEy1 <br /> TOKAY DIALYSIS-DAMTA#2016 Ill <br /> 312 S FAIRMONT AVE 412912016 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> I <br /> CUMIAER NUM4ER 6053303-001 GENERATOR's REGisTRAmON# <br /> 2A.DESCRIPTION OF WASTE 2H CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> �""— CONTT SRS <br /> I U� lI Regulated Medical Waste,n.o ., TB14-(Bio)/ W(Path)44 Gal Tub(5.9 Gu ft) ,• Cu Ft <br /> 62,A61I Regulated Medical Waste,n.o.s., TB21-(Bio)/TP1 S-(Patti)/TY15-(Chemo)20 Gal Tub(2.7) <br /> Gu Ft <br /> I p 6.22.Nil Regulated Medical Waste,n.o.s, TMG-(Bio)/TP42-(Path)/TY49-(Chemo)37 Gal Tub(4 8) <br /> Cu Ft <br /> I• UN3291 Regulated Medieal Waste,n.os., <br /> 6.2,PGI) TB35-28 Gal Tub(Bio)(3.5 cu ft) Cu F1. <br /> W UN3291 Regulated Medlin!Waste,n.os., -4g Gal Tub Bio $.4 cu ft <br /> Z 6.2,PGII )( Cu Ft <br /> (� U�291 Regulated Medical Waste,n.o.s., WB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.94 cu ft) <br /> Cu Ft <br /> 6 2,pee,Regulated Medical Waste,n.os., WB4'A-(Blo)/PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft) <br /> Cu Ft <br /> 6 2 Pell Regulated Medical Waste,n.o.s, KRB®—Biosystems Cardboard Box(4.2 cit ft) Cu FL <br /> 3 Ali Regulated Medical Waste,R.as., <br /> U t �^ Cu F <br /> 3.Generator's Certification:"i hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu FL <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and <br /> are In all respects in proper condition for transport according to applicw)euable international and national governmental regulate <br /> Printed/iyped Name ' v ° Signature Date <br /> 4.TRANSPORTER 1 ADDRESS: Phone# <br /> w Stelrlcycle,Inc. ® T HS IS C Through Shipment Applicable Permit Numbers: <br /> 11875 Whitie Rork Rd 3400 <br /> a. Rancho Cordova,CA 95742 <br /> a a TRANSPO ER CERTIFICATION:Receipt of medk�l waste as bed b ve. <br /> Pnnttiype Name =' �� -p'�• Sigrratu Daie`�`�1`�``1 ��" <br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#. <br /> aNriApplicable Permit Numbers: <br /> a: <br /> c <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrintM pe Name Signature Dale <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#.- <br /> Applicable <br /> :Applicable Permit Numbers, <br /> M a INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION.Receipt of medical waste as desonbed above. <br /> PrinMpe Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> JJ <br /> BA Designated Facility. OB.Alternate Factitiy: [:]8C.Altemate Facility: ❑8D.Alternate Facility. <br /> ricycle, Inc. Sttericycle. Inc. Steriaycle, Ino. <br /> 4812 Starr Dr. 90 N. Foxboro Drive 4135 W. Swift Ave <br /> LL Yuba Clay. CA 55893 North Salt lake,LIT 84054 Fresno,CA 93722 <br /> (630)756-tz£85 ti (Sol)93e-1174 (530)755-0585 <br /> TS/OST Sp, 3A448I.JA-36 TS/OST 22 <br /> TRE I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> I— recei flaccordance with the requirement outlined in that authorization. <br /> .i Pdntlryp'g'Na , -" " Signature Date <br /> V �1' rr•y ¢ • ., <br /> h r• , „;r' :. . ir #erred containers, tXt ft to `Yuba City, CA Fresno, CA <br /> ;r <br /> nsferred containers, Cif ft to: or Fresno, CA <br /> ORIGINAL <br />