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c ® MEDICAL WASTE TRACKING FORM NUMBER <br /> aS <br /> ®*Q tericyrd " IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800 424-9300 STANDARD MANIFEST 001-10-06-s7D <br /> " pret"OngkoploAkludnxtst. Route#: 036— 6 CUSTOMER NO.21132 MDRC00JPNR <br /> 1.Generator's Name,Address and Telephone Number <br /> � ATTN:EIS GrtlyA � � 1But <br /> TOKAY DIALYSIS-DAVITA#2016 1 <br /> 1111111111 <br /> 312 S FAIRMONT AVE 7/22!2016 <br /> LODI,CA 95240-3840 (209)369-5418 <br /> CusToMEn NumsER 605330"01 GENERATOR'S REOWMATION If <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> UN3291 Regulated Medical Waste,n 0. - COT ERs <br /> 6.2,PGd TB14-(Bio f 14-(Path)A4 Gal Tub( .Q cLt ft) ® Cu Fc <br /> 6 291 Regulated Medial Waste,n os., TB21-(Bio)f TP154Path)I TY15-(Cherno)20 Gal Tub(2.7) <br /> Cu Ft. <br /> ccU'0 4 !PGII Regulated Medical Waste,n os., TB49-(Bio)/TP49-(Path)/TY48-(Chemo)87 Gat Tub(4.8) Cu Ft <br /> a 6 23PGI�Regulated Medical Waste,n os., T935-2B Gal Tub(BID)(3.5 cu ft) Cu Ft. <br /> W UN3291 Regulated Medical Wasts,n.o s., -48 Gal Tub Bio B.4 cu ft <br /> iZ 6.2,PGI! -B ( )( ) Cu Ft. <br /> C7 sN,3291Regulated Medical Warts nos, W831-(Bic)/WP31-(Path)f WC31-(Chemo)31 Gal Tub(4.14 cu ft) <br /> Cu Ft <br /> 6 23201 Regulated Medical Waste,n os., WB43-(Bio)/PW43-(Path)f CW43-(Chemo)43 Gal Tub(5.7 cu ft) <br /> Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s., KRB„_-Btasystetns Cardboard Box(4.2 cu it)6,2,PGJl Cu Ft <br /> d 2329 I Regulated Medical Waste,n os., Cu Ft <br /> 3.Generator's Certification:et hereby declare that the contents of this consignment are fully and accurately TOTALS Cu Ft <br /> described above by the proper shippping name,and are classified,packaged,marked and labelledfplacarded,and <br /> are In all respects In proper condcUon for transport according applicable international and national governmental regul o <br /> l� <br /> Printed/Typed NameW= MAW) Signature D <br /> 4.TRANSPORTER 1 ADDRESS: I Phone#: (atm) IU.VM22 <br /> w Stericycfe,Inc. ® This is a Through Shipment Apphcabie Permit Numbers: <br /> �E rE 11875 VWde Rock Rd 3400 <br /> M a. Rancho Cordova,CA 95742 <br /> a Q TRANSPORTER CE IFICATION:Receipt of medical waste as 16 d <br /> Print/Type Name —Signal 7e rDate <br /> S.INTERMEDIATE HANDLER 2/TRAOPORTFR2 ADDRESS: Phone#• <br /> Applicable Perms Numbers. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> f°rinMpe Name Signature Date <br /> O 4.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone If. <br /> le <br /> Applicable Permit Numbers: <br /> R INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:III Receipt of medical waste as described above <br /> ArinUType Name Signature <br /> Date 1 <br /> 7.DISCREPANCY INDICATION <br /> i I <br /> Designated Fncnity. Q 80.Alternate Fadltty Q eC Alternate Faclillyn, SD.Alternate FacEgty. <br /> SYericyde,Ino. Stericycle, Inc. Stericycle, incl. <br /> a 1B12 Starr Dr. 90 N. Foxboro Drive 4135 W.SWR Ave <br /> LYuba City, CA 95993 North Salt Lake. UT 84054 Fresno, CA 93722 j <br /> g (530)755-050 (801)938-1171 (530)755-0586 <br /> I, TS/OST 80 3A-448/JA-30 TS10ST 22 <br /> TREATMENT F+AC►INO <br /> ' Vit• v been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br /> I— received tPi �t rdance with the requirement outlined In that authorization. i <br /> s c ro— <br /> Printlrype Hain® Signature Date <br /> M `Traizsfei^red contaa,nvers, it tar. city',C a- rte ,CA <br /> o <br /> ca a- 11X741, <br /> ,.:t'ran rind containers. cu It to: or Fresno, CA I <br /> ORIGINAL. i <br />