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MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .800:424-9300 STANDARD MANIFEST 001 .03.21•N0CA
<br /> Route #. 703 4 CUSTOMER NO, 21132 MDTKOOOGML
<br /> I 1 . Generator's Name, Address and Telephone Number II
<br /> I TOKAY DALYSI DAVITA #2016
<br /> " 111111111011, � 111111111110 1 HIM
<br /> 1312 S FAIRMONTAVE 3/22/2022
<br /> LODI , CA9524O" 840 ( 208 ) 3 69-541 8
<br /> CUSTOMER NUMBER 6053303- 001 GENERATOR'S REGISTRATION #
<br /> f 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C4 140. OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s„ , cONTA1NE
<br /> 6.2, PGII TL I4 - (Bia ) I P1Q -( Path ] Tl W( Incinerate ) 44 Gal , Tub 5 . 9Cuft) � � � Cu Ft.
<br /> 623PGIiRegulatedMedicalWaste, n.o.s„ T821 _ (Blo ) TP15-(Path )._TY1 &( Chetno ).. 20 Gal . Tub {.17 Cuff .) Cu Ft,
<br /> I OUN3291 , Regulated Medical Waste, n,o.s,, n
<br /> 6.2, Poll TBel 9- ( Bia ) .TY49-(Cherria ) T149-( lnclnerate ) . ,7 Gaal . Tu (4 . 9t Cuft . ) Cu Ft.
<br /> Q 623PGIi Regulated Medical Waste, n.o.s,, W134 w-( Blo ) CW4 Z- (Chserno ), .YVX4 3-( Pharni ) 43 Gal . Tu ( 6 . 71Cuft . ) Cu Ft
<br /> 1 IZ 623PGiI 91 Regulated Medical Waste, n.o.s., KR ( Bio ) Gal . Conitgatecl Bax (4 . 32 Cult ) Cu Ft.
<br /> UN3291 Regulated Medieai 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 /> 6.21 PGII L00 Cu Ft,
<br /> UN329t , Regulated Medieai Waste, n,o.s„
<br /> 6.21 PGff Cu Flo
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately 70TAt_S ► 7 * 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
<br /> y�for
<br /> J�transport rding to applicable International and national governmental regulation .'
<br /> PdntedTyped Name �VV SI nature Date
<br /> & TRANSPORTER 1 ADDRESS: I P ne C ( 2O9) 294_7114
<br /> StCrlcyclC , Inc . TMS iS a Through Shipment UpIlcable Permit Numbers;
<br /> 7575 R A Bridgeford Rd . TS/OSTm80
<br /> �
<br /> NStockton , CA 95206
<br /> oM, 0a< TRANSPORTERWTIFICATION : Receipt of medical waste as described ve. /,OIL7& �Print/Typo Name OWL Signature rrL c Date 03
<br /> 54 INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M:
<br /> Applicable Permit Numbers:
<br /> Eui
<br /> FA INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION : Recelpt of medical waste as described above.
<br /> Printlrype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone C
<br /> Applicable Permit Numbers:
<br /> z INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Air
<br /> Qz
<br /> IE — Print/Type Name Signature Date
<br /> 7, DISCR
<br /> M
<br /> } Designat Faclilty: (] 8C. Attemate Facility: 8D. Alternate Facility:
<br /> wt ricycle , Inc . r ► + ot + j2 Vjt:1d1vnA
<br /> y ie , Inc . (Incinerator) Btericyale , Inc , (Autoclave) Covanta Marion , Inc
<br /> 4 Im tell, R A 6ridg �nrd Fid . 9G fel , r" xboro Drive 2775 E . 26th St , 43'60 Brookiake }load PIE
<br /> L 8 t kion , CA 952013 (North S It Lake , UT 39054 Vernon , CA 90053 Brooks, OR 97305
<br /> z 31 (20 )294 - 791 301 93 = 1179 8881783-7422 ?
<br /> W
<br /> (
<br /> _ 0,. . 93 039
<br /> I T81 T80 94 ' 3A-4 g A_3b Perrot # 364
<br /> TREnIM 114
<br /> P MENT FACILITY: I certify 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 /> Print/Type Name Signature Date
<br /> ORIGINAL
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