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} MEDICAL WASTE TRACKING FORM NUMBER
<br /> lir S 4P. CICyC � P..� 1N CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800-424-9300 STANDARD MANIFEST 001 -03.21 •NOCA
<br /> Route #. 703 - 18 CUSTOMER No. 21132 MDTKOOOJI-IQ
<br /> 1 . Generator's Name , Address and Telephone Number
<br /> ATDIALYft~ Crowley
<br /> DAVI1111111111111111111111111II
<br /> TOKAY DIALYSIS-DAVlTA #2016
<br /> 312 S FAIRMOZ`ITAVE 4 /119/2022
<br /> LODI , CA 95240- 3840 (209) 3694418
<br /> 605 :1303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION If
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 20. NO. OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., Ai RS
<br /> 6.2, PGII t 131A -(f3ici}_�Q '1'1� 1 �f -( Csath) 1 'Y14 -( fitcUtorata) �t4 Gal . 7"itla 54 u JC A Q cu Ft,
<br /> UN3291 Regulated Medical Waste, n,o.s„ ' f•Dl1 _(DIo ) � P16 -(Path).__ _ TYi a-(Gtlemb )u 20 Gal . Tub (2 .7 Cult )
<br /> Cu Ft.
<br /> O UN3291
<br /> PGII Regulated Medical Waste, n.o.s„ TO,� fl_(Oib )�_ _1'Y t3 -(Chet7j4)_� T149 -( ItycilleCate } 7 GaleTtt (b• .9 00.)
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,642t PGIl X4, 3 D1a C N 3 _ Ghemo 1NX43 Pham? 4, 3 Gal . Tut 5 .7Cuft .) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s.,
<br /> Z 6.2, PGII Kli (Bio) Gal . Corrugated Box (4 .32 Cuft .) 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 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu FL
<br /> 3. Generator's Certification: "I hereby declare that the contents of this consignmgnt are fully and accurately TOTALS ► O e 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 for tran laapplicable international and national governmental) mulct ns"
<br /> Printedfryped Nam r nater
<br /> -�►-� Date
<br /> 4. TRANSPORTER I DRESS: Phona lla j9) 29cF-711
<br /> .�stt? rtCy C , IIIc . TINS IS a Through �iliipirient Applicable Permit Numbers:
<br /> c 787.'1 fZ rlc cit,ford Rd f' :;!(78 'f� 80
<br /> 2 N Stockton , CA 95206
<br /> MCL 4 TRANSPORT RtERTIFICC N : Receipt of medical waste as descri �ove
<br /> PrinUiype Name t t`11n Slgnature �� (l Date Q�
<br /> TE HANDLER 2 / TRANSPORTER..` 5. INTERMEDIA 2 ADDRESS: Phone H:
<br /> Applicable Permit Numbers:
<br /> x
<br /> INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Printrrype Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> cc
<br /> b w Applicable Permit Numbers:
<br /> WJ
<br /> 2 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinIfType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> BA. signaled Faciik�'I AN E 8B. Alternate Facility: 8C. Alternate Facility: BD, Alternate Faclilty:
<br /> _. ei'i Ldio
<br /> ncSE ; tyrlc IN , IrrC . inslnarflt�� r steric .la lrlc . Autoclave �' ovpnttt tiiarl ,�n , lnc
<br /> 7 & 7rld�fafordVED 90111 , oxboroDrivo 2776 E , 26th St, x} 850 Dr+�oklake Road NE
<br /> Stt A 5 ' ^ ,y North ' alt Lake , Ur 8140611 Vernon , CA 80068 Brooks, OR 97806
<br /> z � t14u2022u, ( (801 ) 36 ffrt2 f:80 3AA Wk36 Permit # 361
<br /> FTR11* 1LISAvel r,�h�t 1 hav been authorized by the applicable state agency to accept untreated medical wastes and that I have '
<br /> received the aBdM4ndIw s`t in acc rdance with the requirement outlined in that authorization ,
<br /> Print/Type Name Signature Date
<br /> ORIGINAL
<br />
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