|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> i� IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800.424-9300 STANDARD MANIFEST
<br /> StericyCle`
<br /> Route * 706 4 CUSTOMER NO, 21132 MDTK00DMRM
<br /> I . Generator's Name, Address and Telephone NumberATTN : Eric Crowley
<br /> � TaKAY DIALYSIS-DAVITA #12016
<br /> 312 S FAIRMONTAVE 512012022
<br /> LODI , CA95240_3840 ( 209) 369 -5410
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 284 CONTAiNEH TYPE 20. NO, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., u T ERS
<br /> 6.2, PGII TD14 -jaia ) TP � 4� ( Patn ) T f4 - ( lnoineTate ) 44 Cat . Tulp 'u Cu Ft.
<br /> 662, PGII
<br /> Regulated Medical Waste, n.o,s., TB21 _( Blo ) TPI6-(Path ) _,_,,., TY1 &(Cherno )-„_. 20 Gal . Tub ( �' .7 Cult )
<br /> Cu Ft.
<br /> OUN3291 Regulated Medical Waste, Tfa4f)_( Bio ) TY49- (Chemo ) T14941n0inerate ) _ _ r37 Gal . Tu (4 . 0 Cuft. )
<br /> 62, PGII Cu Ft.
<br /> 0 UN3291 Regulated MedicalWasle, n.o,s., M13 ( Bic1 ) CVV48- (Cheino ) WX42"( Phann ) 43 Gal . TO ( 5 .7Cuft , ) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., Ela Gal , COrtU aced Box 4 . 32 CUft,
<br /> Z 6.2, PGII ( ) ----- ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s., Cu Ft.
<br /> 6.2, PGI)
<br /> UN3291 Regulated Medical Waste, n,o,s„
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, %o.s.,
<br /> 6.2, PGi) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„
<br /> 6.2, PGiI Cu Ft.
<br /> � )
<br /> 3. Generator's Certification: 41 hereby declare that the contents of this consignment are fully and accurately TOTALS t 7 "7 Cu Fte
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded. and oeeoeoe
<br /> are in all respects in proper condition for transport according to applicable International and national governmental regula ions"
<br /> Printedrlyped Name W2 i SI nature Date
<br /> 4. TRANSPORTER 1 ADDRESS: Rhone #: -
<br /> Ste
<br /> rtcycle , tr1G . This is a Through Shipment A Ilcable Permit Numbers:
<br /> CC CC 707' 5 R A Bridgeford Rd. TSIOST 80
<br /> 2 XL Stockton , CA 952DB
<br /> Now a a TRANSPORTER CE IFICATIO a ipt of medical waste as descri e.
<br /> rr h qn �,� --- 2
<br /> Print/Type Name � , ()., I Signature � � ��- Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> 6: 1
<br /> Applicable Permit Numbers:
<br /> 2
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVType Name Signature Date
<br /> w 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> �M a a Applicable Permit Numbers:
<br /> Sa+
<br /> R a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> 4 z
<br /> — PrinUtype Name Signature Date
<br /> 7. DISCREPANCY INUICATiON
<br /> Mime
<br /> A. Designated Facility; C3 Be. Alternate Facility: [] act Alternate Facility: 8D. Alternate Facility:
<br /> jS encycle , inc . (Autoolave) Rtericycle , Inc . (Incinerator) Stercyc(e , Inc . (Autoclave) Covanta Marion, Inc
<br /> SEEN
<br /> a g 7876 RA Bridgeford Rd . 90 No Foxboro Drive 2776 E . 28th 5t, 4850 Brooklake Road IdE
<br /> LL 1 5tacicton , CA 96208 Norah Salt Lake , LIT 64054 Vernon , CA 90058 Brooks, OR 97305
<br /> w 0311 (209 )294-7114 (601 )938 - 1171 (680)783- 7422 (506 )393- o890
<br /> 3AA481JA46 Permit # 364
<br /> U 7receIVed
<br /> �"� }}��,, i certify th I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />€ t- a'bt leftited waste In accordance with the requirement outlined in that authorization .
<br /> rN Signature Date
<br /> ell
<br /> 40
<br /> be
<br /> E
<br /> ORIGINAL
<br />
|