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MEDICAL WASTE TRACKING FORM NUMBER
<br /> *.*..p Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800.424^9300 STANDARD MANIFEST 001 .0302t•NCCA
<br /> Rote # 706A4 CUSTOMER No. 21132 I q
<br /> 1 . Generator's Name, Address and Telephone Number ff (f ## II
<br /> ATTN : FI•i0 Cl'DwICv
<br /> TOKAY DIALYSIS-DAVITA #2016
<br /> 312 S FAIRMONTAVE 3 /11 /2022
<br /> LODI , CA95240-3840 ( 209) 369-541 £
<br /> CUSTOMER NUMBER 60573113- 00 1 GENERATows REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 28• CONTAINERTYPE 2C, NO. OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., CONTAINER
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<br /> UN3291 , Regulated Medical Waste, n.o.s.,
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<br /> X UN3291 , Regulated Madleal Waste, n.o.s, ,
<br /> G 6.24 PGII T _ ( ,i n ! - i a o a i T I q. 1 Cu Ft.
<br /> dUN3291 , Regulated Medical Waste, n.o.s.,
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<br /> W UN3291 Regulated Medical Waste, n.o,s.,
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII
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<br /> UN3291 , Regulated Medical Wasie, n.o.s.,
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<br /> UN329i , Regulated Medical Waits, n.o.s.,
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<br /> 3. Generator's Certification : "I hereby dQclare that the contents of this consignmgnt are fully and accuratelyTOTALS 10 4 Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labeiled/piacarded, and
<br /> are in all respects In proper condition for transport a ording to applicabie nternational and national governmental regulations )
<br /> Printed/Typed Name yr t Signature Date r '✓
<br /> 4. TRANSPORTER 1 ADDRESS: NOPhone #: 309? 94-7114
<br /> w Applicabt arm t umbers:
<br /> ,. steftycle , Inc . This is a Threelc9h Shipment i a 0 7875 R A Bridgefortt Rd . T%S/OST SO
<br /> Stocklon CA 9520
<br /> I ems. Za TRANSPORTER tEER-,T,I,FICAT IO ISO: Receipt of medical waste as described ve. 7p f (1Q'y
<br /> ~ PrintlType Name + ` � � Signature t Date OJ r llr�
<br /> Se INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS : Phone #:
<br /> cc Applicable Permit Numbers:
<br /> w
<br /> W
<br /> 1 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> is
<br /> Prinl/rype Name Signature Date
<br />[ 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> w 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 7. DISCREPANCY INDICATION
<br /> 8A. Designated Fecll B. ANemate Facility: 8C. Attemate Facility: 8D. Alternate Facllfty:
<br /> tericycle , Irtddi`aVe St licyole , Inc . (Incinerator) StericVcle , Inc . (Autoclave) GDvanta h�larion , Inc
<br /> If
<br /> I M 706 R4 MANE) 90 90 J . Foxboro Drive 2775 E , 26th Wt, 4850 Brooklake Road NE
<br /> t— Stbekton , 95200 No i Salt lake , LIT 54054 Vernon , CA 90059 Brooks, OR 97305
<br /> w g (209 )204 -7 ( 1366 )78'- 7422 (505 )3993- 0890
<br /> � � � �, � 2fl22 (R0 )936 -9171
<br /> I— T310ST-80 3A- A 8/61A-313 Ferrnit # 354
<br /> REATMENT FACT : I ce that I ha been authorized by the applicable state agency to accept untreated medical wastes and that I have '
<br /> ecelved tCW1bpV I that
<br /> in acc rdance with the requirement outlined in that authorization .
<br /> Signature Date
<br /> E
<br /> I •
<br /> ORIGINAL.
<br />
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