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141111111' 0 MEDICAL WASTE TRACKING FORM NUMBER <br /> A.A Stericycle- IN CASE OF EMERGENCY CONTACT:CHEMTREC 1-800424-9300 STANDARD MANIFEST Oot•iaoe•STD <br /> PMedogPOGO*ftWoft RW Route#- 036- 8 CUSTOMER NO.21132 MDRCOOJ�Ia YX <br /> 1.Generator's Name,Address and Telephone Number ll { { { { { { <br /> ATTN:Eric Crowley <br /> TOMY DIALYSIS-DAVITA#2016 <br /> 312 S FAIRMONT AVE 7/29/2016 <br /> LODI,CA 85240-3840 (209)360-5418 <br /> CusTOMERNUMBER 6053303-001 GENERAT6R%REGISTRATION� <br /> 2A.DESCRIPTION OFWASTE 28• CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UN3291 Regulated Medica!Waste 14- Bit) / 4-(Patti)44 Gal Tub(5.9 cu It) CONTAINERS <br /> 62.PGI! ) $ S t,FL <br /> 6 23 I 'll Regulated Medical Waste,n.o s., TB21-(Bio)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2.7) <br /> Cu R <br /> CC 6 23 G1i1 Regulated Medk al Waste,n.o.s., TB49-(Bio)/TP49-(Path)t TY49-(Chemo)37 GaI Tub(4.9) Cu R <br /> !ORUN3 G9I Regulated Medical Waste,n o.s, TB35-26 Gal Tub(Bio)(3.5 cu R) cu Ft <br /> W UN3291 Regulated Medical Waste,n.o s., T8E4-48 Gal Tub Bi )(o S.4 cu tt) Cu Ft <br /> w 6.2,PGI! ( <br /> 6 2,PG1E Regulated Medical Waste,n,o.s., W831-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14 Cut ft) <br /> t:u Ft. <br /> 6 2, PG1�Regulated Medical Waste,n.os., WB43-(Bio)/PW43-(Path)/CW43-(Chemo)43 Gal Tub(5.7 Cu ft) <br /> Cu Ft. <br /> 6231361!Regulated Medical waste,n-0-s-, KREB_-Biosystems Cardboard BOX(4.2 cu ft) <br /> Ou Ft <br /> 6N3P01!Regulated Medical Waste,n.o.s., q Cu Ft <br /> 3.Generator's Certification:°I hereby declare that the contents of this consignment are fully and accurately TOTALS 110, Ci ) { Cu Ft. <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 ns." <br /> PrintecI Typed Name !V Signature Date g r <br /> 4.TRANS RTER 1 DRESS: Phone#: <br /> (866) lUX742W- <br /> S Inc. D This is a Through Shipment Applicable Permit Numbers <br /> aI 1875 White Rock Rid 34130 <br /> Rancho Cordova,CA 95742 <br /> a TRANSPORTER 91WFICATION:Race p medical waste as describe <br /> QC <br /> F- PrinMpa Date <br /> 5.INTERMEDIATE HANDLER 2 ITPXNSPORTER 2 ADDRESS: Phone#. <br /> SApplicable Permit Numbers. <br /> an <br /> N � <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVtype Name Signature Date <br /> io 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone#. <br /> 1hApplicable Permit Numbers. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> fE— Printflype Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> .Deslgnatod Facility; F1 88.Alternate Facility: 8C.Alternate Facility 81).Alternate Facility <br /> If aStericycle. Inc. Stericycle, Ino. Stericycle, Inc. <br /> If 1812 Starr Dr. 90 N. Foxboro Drive 4135 W.Swift Ave <br /> Yuba City,CA 98993 North Salt Lake, LIT 84054 Fresno, CA 93722 <br /> (1530)7;5.5-05$5 (801)93&1171 (530)758-0585 <br /> JJU TWOST 80 3AA481JA-30 TWOST 22 <br /> a <br /> a TREATMENT FACILITY:I certify.that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> E- received;�b9>�. d ted wa s accordance with the requirement outlined In that authorization. <br /> Print/rype Na 11rne0{i AA t(7� 1'1177 C° Signature — Date <br /> BARRENTransferred cantairlers, Cu#tta - ubaftp;CA Fresno, CA <br /> Transfe"d containers, cu R tit: or Fresno, CA <br /> i <br /> ORIGINAL <br />