|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> •: :� Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTiREC 140044244300 STANDARD MANIFEST 001 •o3-21 •NOCA
<br /> Route * 706 -3CUSTOMER NO. 21132 MDTKOOOT1R
<br /> 1 . Generator's Name, Address and Telephone Number j
<br /> ATTN : Eric Crawley
<br /> TOKAY DIALYSIS-DAVtTA 12016
<br /> 312 S FAIRMONTAVE 7/22/202
<br /> LODI , CA95240-3040 ( 209) 369-541 B
<br /> 6053303- 001
<br /> CUSTOMER NUMBER GENERATOR'S REOISTRATiON N
<br /> 2A, DESCRIPTION OF WASTE 28, CONTAINERTYPE 2C, NO, OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n ,o.s„ C�t�tTAIN
<br /> 6.2, PG11 7614 -(Bin ) TP14 - ( Path ) 7Y14 �{ incinerate ) 44 G I . iuM uft) a 5� CuFt.
<br /> 6UN32291iRegulatedMedicalWaste, n.o,s., TB21 - (Bio ) TP15-(Path ). TY15-( Chemo ) 20 Gal Tub ( 2 ,7 G lt . ) Cu Ft.
<br /> CC UN3291 Regulated Medical Waste, n.o,s„ 176415- (Bio ) TY4S-(Chemo ) T14HIncinerate ) 37 al . Tub (4 . Cult . ) Cu Ft.
<br /> X 623 PGIIRequlatedMedicalWaste, n.o.s „ VVtS43 (l�ia ) CVA3-(Chemo ), WX434Pharm ) 43 al . Tu 5 . CuQR _
<br /> CU Ft.
<br /> W UN3291 Regulated Regulated Medical Waste, n.o.s„ KR (Bis ) Gal . Corrugated Box (4 . 32 Cuft . )
<br /> Cu Fl.
<br /> �r 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, mots„
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGII 0
<br /> x u Ft.
<br /> 3, Generator's Certification: 1 hereby declare that the contents of this consignment are fully and accurately TOTALS ► 5a 3 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 Ira port according to ap ilcable international and national government ulationa"
<br /> Printedinyped Name SI natur Date
<br /> 4, TRANSPORTER DDRESS: Phone N: 2p9) 29¢7114
<br /> °C leticycle , I c . {� This is a Through ShipmentAppllca*1 Permit Numbers:
<br /> 7075 R A Bridgeford Rd . TS/OST I)
<br /> Stockton , CA 95206
<br /> c oma. Z TRANSPORTS CERTIFICATION: Receipt of medical waste as describe above �1
<br /> Print/Type Name Q-5 t Ilia 7 ^ a ^ a
<br /> ype � Signature Date .
<br /> 5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone N:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVrype Name Signature Date
<br /> 5. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> C Applicable Permit Numbers:
<br /> X1 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION :- Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> A. Designated Facility: 88. Akemete Facility; 8C. ARsmate Faculty: 8D, Altamah Facility,
<br /> Stericyofe , Inc . (Autoclave Stericycle , Inc. (Incinerato ) Stericycle , Inc . (Autoclave Covants Marion , inc
<br /> a 7875 RA Bridgeford Rd . 90 N . Foxboro Dove 2775 E . 26th St, 4560 I�rooklake Road Ne
<br /> Stockton , CA 95208 North Saft Lake , UT 84054 Vernon , CA 90068 Brooks, OR 97305
<br /> W ,.. _ _ (209 )294411.4 (801 )938 - 1171 (806 )783-7422 (505 )3g3-0890 I
<br /> r +Tl 'I - _l lUE 3A-448/JA-38 Perm #t 3134
<br /> GAH
<br /> A h TREATMEN10ACiILITYY&, Certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F received the above indicated wastes in accordance with the requirement outlined in that authorization .
<br /> LEI PrinVrype Na11L U 2012 Signature Date
<br /> i
<br /> ORIGINAL
<br />
|