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• -- T -- — *—MEDICAL WASTE TRACKING FORM NUMBER
<br /> ®® St@I"ICyC{E" IN GASFrtS EAAEF§ENCg J0ffACT:CHEMTREC 1.BOD•424-9300 S74tt �EEs7 ODI-10
<br /> e Pm�ecilnpis,opiaPaAu,tnpAlSC. 1'itaU[+E 3F: U i CUSTOMER NO.21132 L7i'K C
<br /> 1.Generator's Name,Address and Telephone Number 1 i{
<br /> TOKADIALYSIS- TAX096
<br /> 312 S FAIRMONT AVE 6/24/2016
<br /> LODI,CA 95240-3040 (209)369-5413
<br /> 6053303-00'1
<br /> CUSTOMER Nutaeen GENERArorrs RaarsmAnoN#
<br /> 2A.DESCRIPTION OF WASTE 28 CONTAINERTYPE 20.NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n o s., Q(Bio)/TP14-( ath)44 Gal Tub(5.9 cu ft) CONTAIN Rs
<br /> 6.2,Pali Cu Ft
<br /> UN3291n
<br /> 'Regulated Medical Waste, .o.s., T821-(Bio 15-(Path)/TY15-(Chemo)20 Gal Tub(2.
<br /> 6P�11i7)
<br /> Cu Ft
<br /> ® UN 91�Regulated Medical Waste,n.o s., T849-(81o)/TP49-(Path)/TY49-(Chemo)37 Gal Tub(4.9) Cu�
<br /> a 8 23PGIi Regulated Medical Waste,n.os., TB35-2$Gal Tub(Bio)(3.5 fXA it) Cu R
<br /> W UN3291,Regulated Medical Waste,n oz, TBO4-48 Gal Tub(bio)(6.4 cu ft)
<br /> Z 62,Pall Cu Ft.
<br /> UN3291RegulatedRegulated Medical Waste,n as, Wi331-(Slo)/WP31-(Path)/ C31-(Chemo)3 Gal Tub(4.1 au It) Cu Ft
<br /> UN3291,Regulated Medical Waste,n.o.s., 3-(Bio) P 9-(Pa )1 CW43-(Chemo 43 a u 5.7 Gu ft
<br /> 6.2,Pall Cu Ft
<br /> 6 2 GI�Regulated Medical Waste,n.o.s., KRB_,,,-Biosystems Cardboard Box(4.2 cu ft) Cu Ft
<br /> UN3291 Regulated Medical Waste,n o s.,
<br /> 6.2,Pall r �^s Cu Ft
<br /> 3.Generator's Certill"tion:al hereby declare that the contents of this consignment are fully and accurately TOTALS ® \ L,Cu Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,and `
<br /> are In alt respects In proper condition
<br /> ,for transport acc�oorddiing to applicable international and national governmental regulalm Z'
<br /> Printed(lyped Name ►-' ti Signature Date
<br /> 4.TRANS TWINW1IJREgs: This Is a Through Shipment Phone a:
<br /> a LU 11876 Wh$1IeECRock Rd Applicable Permit Number5400
<br /> I a. Rancho Cordova,CA 55742
<br /> a q TRANSPORTER CE? O�FICATicsrpt of m Tical waste as d
<br /> Print/type Name /^w4m 4V
<br /> Signa Date
<br /> 6.INTERMEDIATE H N LER 2/ ORTER 2 ADDRESS- Phone 8•
<br /> a
<br /> Applicable Permit Numbers'
<br /> �0
<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#•
<br /> Applicable Permit Numbers-
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above
<br /> Print/type Name Signature Date
<br /> 7.DISCREPANCY INDICATfON
<br /> Designated Facility: 813.Alternate Facility: 8C.Alternate Facility. 8D.Alternate Facility:
<br /> Stericytde, Inc. Stericycle, Ino. Sterfcycle, Inc.
<br /> f Q 1812 Starr Dr. 80 N. Foxboro Drive 4135 W.StnriftAve
<br /> u- Yuba City, CA 95993 Notch Salt Lake. UT 84054 Fresno. CA 83722
<br /> 13 (530)755-0585 (801)936-1171 (530)755-0585
<br /> TS/OST S0 3A-448/JA-36 TS/OST 22
<br /> lir -
<br /> T 1L�'I.V: port# that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r°G— in accordance with the requirement outlined in that authorization.
<br /> 1PrInVW8 Signature Date
<br /> r: Transferred' containers, R t ube City, CA Fresno,CA
<br /> "- Transferred____-,_containers, ou ft or Fresno, CA
<br /> a
<br /> �; --•�
<br /> ORIGINAL
<br />
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