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. MEDICAL WASTE TRACKING FORM N <br /> UMBER <br /> SterICyCgeg IN CASW E� EN " ST�t-10 oeD <br /> •i� "NT <br /> CUSTOMER NO. " <br /> 1.GeneratQr�TN' S'EQ Ct'DsWWieayd Tetephorie Number <br /> TOKAY DIALYSIS-DAMTA x/2016 (` <br /> 312 S FAIRMONT AVE 5/27/2016 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> !05330--oar <br /> CUeTOMER NUMBERGENERATOH'9 RtEGtaTRATION# <br /> 2A.DESCRIPTION OF WASTE 213. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical waste, �Bio) 14-(Path)44 Gal Tub(5.9 cu ft) CONTA/i Rs � <br /> 6.2,PGiI - `-^� vP Cu Ft. <br /> UN3291 Regulated Medical Wasto,n.os, TB21- o a emo)ZO URI lUb(,4.() <br /> 62,PGII Cu Ft <br /> X <br /> 62329 I Ragulated Medical Waste,n 0 s. A emo a U (4.81Cu FL <br /> 6N3291 Regulated Medical Waste,n o s., TB36-26 Ga Tu (BID) au Cu Ft <br /> W UN3291 Regulated Medical Waste,a ox, TBt34-48 Gal Tu to)ff-4 cu <br /> Z 62,PGIi Cu Ft <br /> W <br /> UN3291 Regulated Medical Waste,n.os., W831-(Bio)f W93-1-(Path)f WC31-(Che a1 u r u <br /> 6.2,PGfI Cu Ft <br /> 6.2.291 Regulated Medical Waste,n.c s., WB43-(Elio)f-P-W4-3-(Path)/CW43-(C ema a u cu Cu Ft <br /> UN3291 Regulated Medical Waste,n o a, KRB_•-Biosyste, s Cardboard Box(4.2 cu ) <br /> 6.2,PGII Cu Ft <br /> UN329t Regulated Medical West%n as., <br /> 6,2,PGIi Cy <br /> . i <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 0. Q Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and tabelled/placarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulatle <br /> `PrfntediTyped Name �T S sJ /P <br /> 4.TRANFt.�3�rL1EZE8S. TItdS rS 8 Th17Xt1 �? tl(? n� Rhone d <br /> UJIYY IR Applicable Permit Number Q <br /> cc 11875 White Rack Rd <br /> a Rancho Cordova,CA 95742 <br /> a TRANSPORTERCERTIFICATION:Receipt of m Icai v aste as disco Va. <br /> Prfnt/type Name Signatu ✓ Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone : <br /> 114 Applicable Permit Numbers- <br /> 0 <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> ® PrinIt ype Name Signature Date <br /> Us 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone <br /> g Applicable Permit Numbers, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> Pr1nMpe Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> QjkCDasIgnatod Facillty: ®88.Alternate Faclnty: ❑8C.Alternate Facility: rl 80.Alternate Facility: <br /> J -cyde, Ina Sericycte, Inc. Staricyde, Inc. <br /> Ci 1642 Starr Dr. 90 N. Foxboro Drive 4135 W.Svvift Ave <br /> Yuba City.CA 95993 North Salt Lake, UT 84054 Fresno. CA 53722 <br /> (fi80) <br /> 70 -WW (8EI1j 838-1174 (530)7$5-t?'S85 + <br /> Uj TS/OST SO 3A-448/JA-36 TS/QST 22 <br /> Lor•.6 ,✓VM s• <br /> TRV ��¢¢ t ; ave been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> recefvecl� t ocordance witij the requirement outlined in that authorization. <br /> Prfnvftp Game q$' )Signature Date <br /> ;I ran!erre containers, o 4 Cu NAQer=City, CA o Fresno, CA <br /> CM <br /> rc irt, �; 7ransfefred containers. cu It to : or Fresno, CA <br /> ORIGiNAL <br />