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S �G YIC�/CIe` IN CASE OF EMERGENCY CONTACT: CkEMTREC i -800iz4 p300 MEDICAL WASTE TRACKING FORM NUMBER
<br /> STANDARD MANIFEST 001 .03.21 -NCCA
<br /> Route #. 706 -2 CUSTOMER NO. 21132 MDTK0000U9
<br /> I . Generator's Name , Adclress and Telephone Number
<br /> TOKAY D A YrSIS DAVITA #2016
<br /> 312 S FAIRMONT AVE 6/10/2022
<br /> LODI , CA 95240-3840 (209) 369-5416
<br /> q
<br /> CUSTOMER NUMBER 6053303- 001 GENEAATDA,S REnismATiON N
<br /> 2A. DESCRIPTION OF WASTE 20. CONTAINERTYPE 20. Not OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, mo,s„ CONTAINER
<br /> 812, PGII T814 -( Bio), &TP14 -(Path) TY14 -( Inotnerate) 44 Gal . Tub (5aACUft) 16 3S t.,q CU Ft,
<br /> 623PG�IRegulated Medical Waste, n.q.s., 7821 54Path) TY154Chema 20 GaI . Tub 2 7 CuR . Cu Ft.
<br /> 0 UN3291 , Regulated Regulated Medical Waste, n.q,s., TB49 - 310 TY4. 9 - Chemb T149 Indnerate 37 Gal . Tu 4 . 9 CUR . Cu Ft.
<br /> cc 6.2. PGII Regulated Medical Waste, n.q,s.,
<br /> ccVVB43 Blb CV�t 3 - Chemo WX43 Pharm 43 Gal . TO (5100 .) Cu Ft.
<br /> � W UN3291 Regulated Medical Waste, n.q,s.,
<br /> z6320 PGII KR Bio Gal . Cortu ated Box 4 .32 CuR . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n ,q.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.q.s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.q.s, ,
<br /> 6.2, PCu Fit
<br /> 3, Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS 000 , Cu Ft.
<br /> described above by the proper 4hipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In all respects In proper condition for transport according to applicable international and national governmental regulat ns" /�
<br /> Printed/Typed Name Signature Date &
<br /> 4. TRANSPORTER 1 ADDRESS: Phone N;
<br /> cc (209) 294- 7114
<br /> StenGycle , Inc . a This Is a Through Ship ent Applicable Permit Numbers:
<br /> 0 7875 R A Bridggef'ord Rd . TS/OST 80
<br /> � (A Stockton , CA 95206
<br /> 4 ��c TRANSPORTER RTIFICAT ON : Receipt of medical waste as described a ve, rn� Q �
<br /> ~ Printtlype Name eft, GISignature i � �-�' Dale OCitdLI L-�^�
<br /> 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N;
<br /> N Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Printllype Name Signature Date
<br /> iq 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> ls w Applicable Permit Numbers:
<br /> � w
<br /> � INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> a Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> Designated Fsc ) . Al:rnate Facility: 8G, Akemate Facility: 8D, Alternate Facility:
<br /> )At , C
<br /> Ste , cycle , Inc . �ED Static le , Inc . (Incinerator) Sterlcycle , Inc . (Autoclave) Covanta Madon , Inc
<br /> UN 7871 R A Orldgeford Rd 90N , 1=oxboro Drive 2776 E , 26th St, 4860 Brooklake Road NE
<br /> $ to ktorl ; A 9� Not Salt Lake , UT 840x4 Vernon , CA 90058 Brooks, OR 97306
<br /> Z ('� )29{1-'IIIA 0 20L022 . (801 36- 1171 (866 )783 - 7422 (60+5 )393 .0690
<br /> TIC LUFM
<br /> W JS 03 '" 80 3A-4 BMA-36LL Permit # 364
<br /> TRWME o LI IiCb hav been auttlorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> H received tFie move indteeleNacc rdance with the requirement outlined in that authorization.
<br /> Print/Type Name Signature Date
<br /> ORIGINAL
<br />
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