|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle` IN CASE OF EMERGENCY CONTACT: GHEMTREC 1 .800.424.9300 STANDARD MANIFESTool *03.21 •N00A
<br /> Route #. 703 - 19 CUSTOMER NO, 21132 MDTKOODEJO
<br /> 1 . Generator's Name, Address and Telephone Number ff MM II ff II tt
<br /> ATErie y
<br /> DI
<br /> TOKAY DIALYSIS- DAVIDAVITA #2016
<br /> 312 S FAIRMONTAVE 3/1 /2022
<br /> LODI , CA 95240-3840 ( 209) 369-5418
<br /> CUSTOMERfi053303-001 NUMBER GENERATOR'S REQISTRATION $ i
<br /> 2A. DESCRIPTION OF WASTE 2% CONTAINER TYPE 2C. NO. OF 2D. VOLUME i
<br /> UN3291 Regulated Medical Waste, li,n.s, , TB14 - BID CONTAI ER
<br /> 6.2, Pali ( ) TP14- ( Path ) N14-( incinerate ] 44 Gal . Tub 5 , 9Cut)) � Cu Ft,
<br /> 623P9G� IRegulated Medical Waste, n,o.s„ T821 -(Blo ) TP1 & (Path )._TY15-( Chemo ) 20 Gal . Tub (2 .7 Cuft . )
<br /> Cu FI.
<br /> 0 623PG1i1Regulated Medical Waste, n.o.s., T849-(Bio ) TY49-(Chemo ) T149-( lncinerate) 37 Gal . Tu (4 . 9Cuft, ) Cu Ft.
<br /> 642, PG Regulated Medica! Waste, n.o,s., W8 3- Sia CVA 3- Chema M4 Pharm 43 Gal , Tu 5 . 7CUR3 1*76 Cu Ft j
<br /> 6.2, PGII ( ( �� �'{ ) ( i
<br /> W U2, PGII Regulated Medical Waste, n.o,s., KR Bl0 Oaf , Corrugated Box 4 . 32 CA
<br /> tZ 6.2, PGII ( g ( 04 Cu FI,
<br /> V, UN3291 Regulated Medical Waste, n.o,s., ^ / � .
<br /> 612, PGII ai `ft j Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s,,
<br /> 62, 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 a I
<br /> Cu Ft.
<br /> I -[L
<br /> I 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS I O t.J� s Cu Ft,
<br /> described above by the proper shipping name, and are classified, packaged, marked and laballed/placarded, and
<br /> are in all respects in proper connddiitiioonn for tr nsport according to applicable International and national governmental regulations."
<br /> Pdntednyped Name <---^ ' e! . . Sign Date
<br /> 4. TRANSPORTER 1 ADDRESS:
<br /> Stericycie , Inc . Phone N : ( 209) 284-7114
<br /> W
<br /> This is a Through Shipment Applicable Permit Numbers:
<br /> 090 7875 R A Rridgeford Rd . TS/OST 80
<br /> N Stockton, CA 85206
<br /> 0�c TRANSPORTER CERTIFICRION : Receipt of medical waste as described qq tt 1ty�
<br /> ~
<br /> Print/Type Name _ 4_ Signature ti date V �Q 1 aT�
<br /> S, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Applicable Permit Numbers:
<br /> U
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above. I
<br /> Print Type Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone M
<br /> ur
<br /> Applicable Permit Numbers:
<br /> S s a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> Q � z
<br /> f — Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> BA. Designet I 89 Alternate Facility: F1 80. Alternate Facility: I] BD. Alternate Facility:
<br /> n Sterloy � t [ � S ricycle , Inc, (Incinerator) Sterloycle , Inc . (Autoclave) Govanta FAarion , Inc
<br /> u 7875 RA Brid eford Rd . OC N . Foxboro Drive 2776 E . 28th St , 4860 Brooklake Road NE
<br /> Stockton , MAR5114 2022 North Salt Lake , UT 84054 Vemon , CA 90068 Brooks, OR 87306
<br /> Z
<br /> ON (209 )294 -7114 (8 1 )936- 1171 (866 )783-7422 (605 )393-0890
<br /> 2 TSIOST 130 j1h
<br /> -44g1JA46 PerMt # 384
<br /> TREATMENT certify thatve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> f- cordance with the requirement outlined in that authorization .
<br /> Pr!nVType Name SI nature
<br /> 9 Date
<br /> ORIGINAL
<br />
|