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6 0 MEDICAL WASTE TRACKING FORM NUMBER <br /> le.A.4 Sterlicycle* lNCASE OFtEMETENC 07A CHEMTRE01-800424-93DO STANDARD MANIFEST 001.10-MST <br /> ft""ftft*P1&W"V3W Ro ite CI CUSTOMER NO.21132 MDRC00JE51 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN.Enc Crowley <br /> TOMY DIALYSIS-DAVITA#2016 <br /> 312 S FAIRMONT AVE 5/20/2016 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> CUSTOMER NUMBER 6053303-001 GENERMRIS REmsTRA'n0N <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UN3291,Regulated Medical Wade,mos.. TB14-(9io)/1014-(Paths)44 Gal Tub(5-13 Cu ft) cc <br /> 6.2.PGI) Cu Ft <br /> UN3291 Regulated Medical Wate,n.as., T821-(Bio)/1PI5-(Path)/TY15-(Chemo)20 Gad Tub(2.7) <br /> 6.2,PGII Cu Ft <br /> UNS291 Regulated Medical Waste, <br /> 0 6.2,PGIl A-0-1- TB49-(Bio)/TP49-(Path)/TY4131-(Chemo)37 Gal Tub(4.9) Cu Ft. <br /> 291 Regulated Medical Waste,n.o a., TB35-26 Gal Tub(Bio)(3.5 cu ft) <br /> 6.223,PGII Cy Ft. <br /> W UN3291 Regulated Medical waste, <br /> Z 6.2.13811 TENA-48 Gal Tub(sic)(CA cu it) oil Ft. <br /> Uj <br /> aj UN3291 Regulated medical waste,n.os.. WBSj-(E3jO) <br /> 6.2,PrA -(Bio)if WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 cm ft) Cu Ft <br /> UN3291 Regulated Medical Waste,ri.os.. W843-(Bio)/PW43-(Path)/CW43-(Cherno)43 Gat T6b(6.7 CLI it) <br /> 6.2,PGII Cu Ft. <br /> UNS291 Regulated Medical Waste,n-0-s-, KRB_-Biosystems Cardboard Box(4.2 eu ft) <br /> 6.2.PGI1 Cu Pt <br /> UN3291 Regulated Medical to,nos., <br /> 6.Z PGII Cu EL <br /> 3.Generator's Certification:'I hereby declare that the contents of this consignment are fully and accurately TOTALS 10" Cu Ft, <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled1pla rrled and <br /> are In all respects In proper condition for transport according to applicable Intemallonal and national governmental regulations' <br /> X'Printecifted Name Signature Date <br /> 4.TRANSPORTER I DDRESS: ---- Phone# knob) 104-14ZZ <br /> Stedtycte,Inc. ThIS IS a Through <br /> ShIpMent Applicable Permit Numbs <br /> 11875 White Rock Rd W400 <br /> Rancho Cordova,CA 95742 <br /> Z TRANSPORTER C above <br /> __9413TIFICATIO�N"Ipt Of medVd waste,as dem <br /> PrIntfTyps Name Signal,a Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: 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/TRANSPORTER 3 ADDRESS, Phone <br /> Applicable Permit Numbers: <br /> 0 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrIn0ype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> LjOA-Dosignsitect Facility: E]as.Alternate Facility: 8C.Afterriate Facility. 80 Alternate Facility- <br /> ricycle, Inc. Sterleyde, Inc. Stericycle. Inc. <br /> 01 4812 Starr Dr. 90 N. Foxboro Drive 4 135 W. Swift Ave <br /> u. Yuba City,CA 95993 North Salt Lake, Ur 84054 Fresno,CA 93722 <br /> ff (630)766-415S6 (801)936-1171 (5M)7S5-am <br /> TWOST So, 3A-448/JA-S6 TS/OST 22 <br /> het <br /> TR LIA• O—a dla!I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> rebr�? p,IhJ <br /> ;IND <br /> e in accordance with the requirement outlined In that authorization. <br /> frint(TYpe =61 mile** Signature Date <br /> --VLTransfen-ed.L__-;>Q0nWneM. GU R to Fmono.CA <br /> /.%�w"'''N""# fa Cir�--E3-Transferred—containers,_cu ft to. or Fresno, CA <br />