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MEDICAL WASTE TRACKING FORM NUMBER
<br /> o f Sgas tericycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .801)-4249300 STANDARD MANIFEST GD"3.21 •N0CA
<br /> CUSTOMER NO, 21132
<br /> RM - 1400 7,03 W7 MIBTK08465K�A
<br /> 1 . Generator's Name, Address and Telephone um r '
<br /> ATTN : Eric Crowley
<br /> KA
<br /> TaY DIALYSIS- DAVDAVITA �l2R16
<br /> 312 S FAIRMONT AVE 2/7/2023
<br /> LODI , CA 95240-3540 (209) 369- 5418
<br /> QMTOMER NUMBER 6053303- 001 GENERATOR's REQI6TRA110N #
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2c. N0. OF 20* VOLUME
<br /> UN3291 Regulated Medical Waste, n,o.s., CONTAINEJI& 6 t
<br /> 6.2, PGII (' . Cu Ft.
<br /> UN3291 Regulated Medical Waste; n.o.s„
<br /> 6.2, PGII TH31 Bio TP' 1tPa Ch T P T i Cu Ft.
<br /> F 6,21 UN3291 ,1n
<br /> Regulated Medical Waste, ,o.s.,
<br /> FF KP, i §o RX Pharm Corru ate ox 4 .3 Cu Ft.
<br /> Q
<br /> UN3291 Regulated Medical Waste, n.o.s. , RX GAUOT G.asketed Sharp Cont. CuFt Cu F1.
<br /> Z UN3291
<br /> 23PPG11I Regulated Medical Waste, n,o.s., SH GAUQT Gasketed Sharp Cont . ( CUR) Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n,o.s.,
<br /> 6.2, PGII
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s. ,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„ Cu Ff.
<br /> 6,2, PGII
<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.2, PGII
<br /> Cu Ft.
<br /> 3. Gionerstor's Certification: 41 hereby declare that the contents of this consignment are fully and accurately TOTALS Pop � • V Cu Fto
<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 govemmental regulatinvjL
<br /> P dMpgN�aAD}mFe © S ura lle
<br /> 4. DeTRANSTRANSRTERye ? Inc . This 15 5 Through , �i1 $r!i AApplicablePe �
<br /> abie
<br /> 7575 RCA Bridge'ord Rd .
<br /> P 0
<br /> Stoddon , CA 95206
<br /> TRANSPORTERR C FICATiO Ipt of medical waste as desk d7 )OCZ?
<br /> Printllype Name �rn "t1 Signature �� J �."'• '� ��" Data `�
<br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Piton #:
<br /> N
<br /> Applicable Permit Numbers,
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> i 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbere:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> Moll
<br /> 7876 RA Brill 1551 Shelton Clive 2776 E . 2601 St, 850 Brooklake Road NE
<br /> Stockton , Hollister, CA 95023 Vernon , CA 90058 rooks, OR 97305
<br /> 4 ' (866)783-7922 505)393-0£94
<br /> (209)294-719 (885)78 .,-7422
<br /> Tslosmgs 0 errrit # 364pit
<br /> 2023 TS(OST=s3
<br /> TREATMENT FAIL R9. Icertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above Indicated wastes In accordance with the requirement outlined In that authorization.
<br /> PrinVType Name Signature Date
<br /> ORIGINAL.
<br />
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