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MEDICAL WASTE TRACKING FORM NUMBER
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<br /> .ell Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1800424.9300 STANDARD MANIFEST 001 .03.21 •NOCA
<br /> Route # 703 - 18 , CUSTOMER N0. 21132 MDTKOOOH>C
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN: FYlc Cr6trrle},
<br /> j TOKAY DIALYSIS-DAVITA #2016
<br /> 3 .12 S FAIRIVIONTAVE 3129/2022
<br /> LORI , CA95240-3840 ( 209) 369- i 18
<br /> � a5�, 3a �- oar
<br /> CUSTOMER NUMaER GENERATOR'S REGISTRATION N
<br /> 1 2A. DESCRIPTION OF WASTE 2B, CONTAINERTYPE 20. NO, OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINE
<br /> 6.2 . P611 TBI& (Irio )�„TP14 -( Path ) Tl 14-( Incinerate )_. 44 Gal . Tub 5 . 9CUit) 63JCU Ft.
<br /> 823 PGII Regulated Medical Waste, n,o.s., TB21 . Bio TP '15- Fath _TY15- Cherlia �_,•_ 20 Gal . Tub 2 .7 CO .
<br /> CC UN3291 Regulated Medical Waste, n,o.s, , ,
<br /> p 6.21 PGII T [3421- (Dio ). TY401- (Cherno )01 -(incinerate ) ,•7 Gala TU - (4SI CI_IR. ) Cu Ft.
<br /> I" UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII WW 3� ( Bio ) CNAQ 3-(Chemo; ) VtlX43-( Pharrrl ) 43 Gal . Tu , ( 5 . 7Cuft . ) CU Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s„Z 6.2, 13611G11 Its (Bio ) ,�, Gale Conxigated Box (4 . 32 GI_Itt. ) Cu Ft.
<br /> i
<br /> V, UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, Pail Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,2, PGII 7 Cu Ft.
<br /> 3. Generator's Certification: °I hereby declare that the contents of this consignment are fully and accurately TOTALS � ,5J , Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/ c dad, and
<br /> are In all respects In proper conditlon for transport according to applicable international and nation gov nmentai regulatlons"
<br /> Date
<br /> Printedflyped Name
<br /> Signal at
<br /> 4, TRANSPORTER 1 ADDRESS: Phone #t (209) 2 ,.D
<br /> 4-7 '1 '1 =
<br /> °C Stet 'Ieycle , tile . This is a T11t`OLI ll SLtipmeant Applicable Permit Numbers:
<br /> 7875 R A Dtidgeford Rd . S/O4STw80
<br /> Stockton , CA 95206
<br /> RE c TRANSPORTER CERTIFICATIO . Receipt of medical waste as describ
<br /> e ve. i Q
<br /> Print/Type Name "Tw , 61 � Signature ,� fit
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> i
<br /> Print/Type Name Signature Date
<br /> i
<br /> s, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone S:
<br /> Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> Q E
<br /> — Print rype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br />€ I7YAN-El. IS1~
<br /> j!A. ipnetedFeel ji ���V4 j
<br /> emMe Facility: [� 8C. Akemate Facility; 8D. Alternate Facility:
<br /> ar .ycle , Inc . (Autoclav?) ole , Inc . (Incinerator) 5te�icyele , lr,c . (Autoclave) Covanta Marion . Inc
<br />[ a 707 ESA SridgKAa 6-0 Za22 N . oxboro Drive 2775 E . 20th St, 4850 Drooklake Road NE
<br /> F Stoi kton , CA 95208 alt Lake , UT 34054 Vernon , CA 00055 Drooks, CTP 97306
<br /> E, w (20 ' )294 -7114 0- 1571 (886)783--74240 (505 ) 2303- 0890
<br /> Tst ST- 8 ��� JA1 ',8 Permit # 384
<br /> Q
<br /> Uj TREATMENT FACILITY: I certify t aeen authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> t- received the above indicated wastes in accordance with the requirement outlined In that authorization ,
<br /> PdnVrype Name Signature Date
<br /> ORIGINAL
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