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MEDICAL WASTE TRACKING FORM NUMBER
<br /> r�6 St@f ICyCi a IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .80"249311e STANDARD MANIFEST Oo1 .03.21 -N0CA
<br /> Route #. 706 -7 CUSTOMER NO, 21132 MDTKO0004W
<br /> Moot
<br /> 1 . Generator's Name, Address and Telephone Number II ++ ii (I II ff ii II
<br /> ATTN ; Eric Crawley
<br /> TOKAY DIALYSIS� DAVITA #2016
<br /> 312 S FAIRMONTAVE 6/3/2022
<br /> LODI , CA 95240-3844 (209) 369-5418
<br /> CUSTOMER NUMBER 6053303- 001 GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO* OF 2D, VOLUME
<br /> 6232 j� Regulated Medical Waste, n.o.s., T131a _(Blo)�TP14"(Path) TY144ineinerate} 44 Gal . Tub (9.` AR R
<br /> Cu Ft.
<br /> B 23PGII Regulated Medical Waste, n.o,s., krB21 .(aio ) TP15 -(Path)�_TYll 640hemo ) 20 Gal . Tub (2 .7 Cuft.)
<br /> Cu Ft.
<br /> CC p 623PG �I Regulated Medical Waste, n,o.s., T849.(Blo ) TY49 .(Chomo) T1404Incinerate ) 37 Gal . Tu (4 .9 Cuft .) Cu Ft.
<br /> UN3291 Regulated Medical Waste, mo.s.,
<br /> 6.2, PGII tNB434Blo ) CV 43 =(Chemo)M434Pharm) 43 Gal . Tu (5 .7Cuft .) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, mo.s„
<br /> IZ 6.2, PGII Krt (Blo) Gal . ortugated Box (4 .32 Cuft .) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.21 PGII KV9 F Ob C (} P, o ak „ . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., t '
<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
<br /> Cu
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS / 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 acoono tion for transport according to applicable international and national governmental regulations ”
<br /> `
<br /> Printed/Typed Name Signature Date
<br /> 4, TRANSPORTER 1 ADDRESS: Phone #: ( 209) 294- 711
<br /> Stencycle , Inc . This is a Through Shipment Applicable Permit Numbers:
<br /> •7875 R A Bridgeford Rd . TWOST 80
<br /> Stockton , CA 95206
<br /> a TRANSPORTS ' IFICATION : Receipt of medical waste as describve�
<br /> PrinMpe Name ,g✓ V�/ t � Signature e ✓� " � DateHINNINNE
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> snuff I � Printlrype Name Signature Date
<br /> 1 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> wApplicable Permit Numbers:
<br /> i INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> — Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. Designated Facility: 813. Alternate Facility: ❑ 8C. Alternate Fadlity: 171 8D. Alternate Facility:
<br /> .t � tericycle , Inc . (Autoclave) Sterlcycle , Inc . (Incinerator) Ste r cycle , Inc , (Autoclave ) Covanta Marlon , Inc
<br /> a 7876 RA 8090ord Rd , 901411 , Foxboro Drive 2775 R . 26th St, 4660 Brooklake head NE ,
<br /> H Stockton , CA 95206 North Salt Lake , UT 84054 Vernon , CA 90069 Brooks, OR 97306
<br /> Z (209 )294411A1 )936 - 1171 (966 )7834422 (505 )393-0990
<br /> T -TNr,owl " 3A 9/JA- 36 PerMt # 964
<br /> T1 1 R ATMENT FACILITY: ' 1 certify that 1 hav been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> f— A recbIved the above Indicated wastes in acc rdance with the requirement outlined In that authorization .
<br /> Prin� ype Name ��tyt'i 1J ,�� t Signature Date
<br /> ORIGINAL
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