|
• ~MEDICAL WASTE TRACKING FORM NUMBER
<br /> ®,,® $$ericycie• IN
<br /> • ►mreci,,r naiskCAS FtSTANDARD MANIFEST 001-10.08-SD
<br /> oe a - Ft
<br /> CUSTOMER No.21132 MDRGtIOJLUE
<br /> 1.Generator's Name,Address and Telephone Number {{ [ {{ [
<br /> ATTN;E13c Crowley
<br /> TODAY DIALYSIS-MATA#2016
<br /> 312 S FAIRMONT AVE 71112016
<br /> LODI,CA 95240-3840 (209)369-5413
<br /> CUSTOMER NUMBER 6053303-001 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2 CONTAINERTYPE 2C. NO.OF 20. VOLUME
<br /> 6 2%,Regulated Medical waste,n o . 14—( i0)/ 14-(Path)44 Gal Tub(5.9 Cu ft) CONTAINERS
<br /> s Cu FL
<br /> 6N3291 2. Regulated Medical Waste,n.o.s., T621-(Bin)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2.7) cu Ft
<br /> p s,�il Regulated Medical Waste,n oz., T849-(Blo)/TP49-(Rath)/TY49-(Chemo)37 Gal Tub(4.9)
<br /> a Cu Fl.
<br /> 6N32 1 Regulated Medical Waste,n.o s., T835-213 Gal Tub(BIO)(3.5 c u ft) Cu Ft
<br /> QC
<br /> W ua32sa Regulated Medical Waste,n o 8, TBLM-48 Gal Tub(Bic)(6.4 Cu fl;)
<br /> Z 6.2,PGI Cu Ft.
<br /> sl Regulated Medical Waste,n O.L. WB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 ext ft
<br /> Cu Ft
<br /> 6UNN3 11I Regulated Medical wash,n os., W843-(Bio)/PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 cu ft) Cu Ft
<br /> 62N%,Regulated Medieal waste,n o s., KR Biosystems Cardboard Box(4.2 cu fit)
<br /> 0=1 PA Cu FL
<br /> 6.2. 1I Regulated Medical Waste,n. . ,� "Uj CIL ` n� r Cu
<br /> EL
<br /> 3.Generator's Certilicatlon: a that the contents of this consignment are fully and accurately T®7'ALS , '� (�.}, t 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 applicable International and national governmental regu 1 ns." 1
<br /> Printetltryped Name R r Signature ode
<br /> Date j r
<br /> 4.IRAN RT,E DD ESS pipe
<br /> #:
<br /> `t'en dee,Inc, ® This is a Through Sitiirmers. pi Applicable Permit Nu
<br /> 11875White Rack Rd `540,
<br /> N Rancho Cordova,CA 95742
<br /> 'q TRAIVSPORTIRTIFI 1`t:Race i of medical waste as described t��
<br /> PdntYlype Name Signature Date 1G(,
<br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#
<br /> jig
<br /> Applicable Permit Numbers
<br /> v,2i 0
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> Printrrype Name Signature Date
<br /> &INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS' Phone#:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above
<br /> — Prkrt/fype Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> Designated Facility: 1171 ea.Attemate Fealty: 8C.Alternate Facility: SD.Alternate Faculty --j—.._
<br /> r-Marit ycle,Inc. Stericycle, inc. Stericycle. Inc.
<br /> 1512 Starr Dr. - goN. Foxbarc Drive 4135 W. Swift Ave k j ILEO fit,? •2-7 -'s�—
<br /> Yuba City, CA 95993 North Salt Lake, UT 84054 Fresno. CA 93722 a.-5
<br /> (530)755-0586 (801)938-1171 (530)755-0585
<br /> R
<br /> CV
<br /> T_ 0ST ea 3A-44e/JA-38 TS/OST 22 g3 74Gc� ,
<br /> F -14
<br /> TREATMENT ' e CJ _�""re�been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> fE received th1e �israYdance with the requirement outlined in that authorization.
<br /> Prkd//Ww Name Signature Date
<br /> Q iff5firans,ferred, containers, cu&10 ire sna, CA +
<br /> Q -,,4; -yt / rreai containers._ j_�F► cu it _o Fresno, CA I
<br /> ORIGINA
<br />
|