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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �:•� Si.}er{cycle' IN CASE Off WY Op ff*. ;SHEMTRECi4*424.9M s 1jffljd1 %03.21 •NOCA
<br /> ' CUSTOMER NO, 21132
<br /> 1 . Generator'N{ i , & ddress aal�deyelephone Number
<br /> Ta KAY DIALYSIS DAVITA #2016 I{ I IIIIII ( Illillll111I11{I I �IIIIlIIlII{ IIIIEII II I
<br /> 312 S FAIRMONTAVE 10/18/2022
<br /> LODI , CA95240-3840 ( 209) 369-5418
<br /> 6053303- 001
<br /> CvsTOYER Numil GENERATOR'S REWMATM M
<br /> 2A. DESCRIPTION OF WASTE 29, CONTAINER TYPE 2C, NO, OF 21), VOLUME
<br /> UN3291 Regulated Medical Waste, n.o,s., T814 "(Bl0 ) TP14-( Path) TY14-( incinerate ) 44 Gal . TybCM.V1J
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., I 1521w (li a IJ MO 1 20 1.55111 . 1 O 0.
<br /> 6.2, PGII Cu Ft.
<br /> X UN3291 Regulated Medical Waste, n.o.s., l0 _ emo ,_ _ nanera e Galt IU u .
<br /> 6.2, PGI) Cu Ft.
<br /> 6 232911 Regulated Medical Waste, mo.s. , IO �- cerYlO ) StTn 8 ' U �� • Cu FL
<br /> W UN3291 Regulated Medical Waste, n,a.s., 10 Gal , Corrugated OX , v U .
<br /> Z 6.2, PGII Cu Ft.
<br /> LU
<br /> JJ 642,UN3291 1I Regulated Medical Waste, no.s„
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n ,o,s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.os.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> 3, Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS D Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In all respects tri proper condition for transport according to applicable International and national governme Lregafatignl
<br /> PdntedTjpod Name Sig rientto •
<br /> 4. TRANSPO� WeE��C Phone 11: NSOUVI
<br /> 4 This Is a Through Shipment Applicable Permit N �.
<br /> 1 7875 R A Bilidgeford Rd . 15swr so
<br /> Stockton , CA 95206
<br /> IL Z TRANSPORTER ICATION : ipt of medical waste as describef Q'/
<br /> PdnUType Name Ua►� i Signature "'_ _' Date t o 1 I O l wz'.
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone N.
<br /> N
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> 51 INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone 8:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATIONetaedeipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> pell f1B. Albrnate Facility: SC, ANomah Fac11Ny: BD, ANemsb Facllky:
<br /> p Stericycle , a tericycle , Inc . (Incinerator) Stericycle , Inc , (Autoclave) Covants Marion , Inc
<br /> ej
<br /> 4 11 7875 RA 0 N . Foxboro Driae 2775 E . 28th St, 4650 Brookiake road NE
<br /> I ;, � Stockton , C qq9 forth Sait Lake , UT 84054 Vernon , CA 9gg58 Brooks, OR 97305
<br /> (2M�294 1. 1 9 022 801 )936- 1171 (868 )783 -7422 (505)393-0ee0
<br /> TS3C PT _ A4148/JA46 Perrrvt # 304
<br /> T EATM I at,jhe been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r �s Iordance with the requirement outlined in that authorization ,
<br /> 410 PdnVType Name Signature Date
<br /> ORIGINALI
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