|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stericycle IN CASE OF EMERGENCY CONTACT: CHEMTREC 14K*4244300 STANDAFID MANIFEST Oct-c3.21 •NOCA
<br /> Route # 706 . 16 cusToMERNo. 21132 MDTM001113C
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN : Erie Crowley
<br /> TOKAY DIALYSIS-DAVITA # 016
<br /> 312 S FAIRMONTAVE 10/14/2022
<br /> LODI , GA952411-3840 : ( 209) 3 1 69w5418
<br /> 6053303-001
<br /> CUSTOMER NUMBER GENERATOR'S REOIaTRATioN N
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF 20. VOLUME
<br /> UUN322911I Regulated Medical Waste, n.o.s., TB14 - (Bio ) 2TP14-(Path ) TY14 - (Incinerate ) 44 Cal . T b642, ot Cu Ft.
<br /> 6232P9i Regulated Medical Waste, n.o.s., TB21 �(Blo ) TP1 &(Path) TY1 &( ChemD ) 20 GalGli . Tu (2 .7 Cuff . )
<br /> Cu Ft.
<br /> M UN3291 Regulated Medical Waste, n.o.s., TB49-(81o ) TY49-(Chemo ) T14941nclnerate ) 37 Gal . Tub (4 . 9 Cut. )
<br /> p 6.2, PGII Cu Ft.
<br /> 62391 Regulated Medical Waste, n.o.s., W6434131o ) C\M3- (Chemo ) VV%43 Pharrn ) 43 Gal . Tub ( 6, 7im ) � . Cu FL
<br /> W UN3291 Regulated Medical Waste, n.o.s. , KR (Bio) CCorrugated Coated Box 4 .32 Cult. )
<br /> rZ 6.2, PGII ( Cu Ft
<br /> a UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 642, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 642, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o•s.,
<br /> 6.2, PGIi Cu Ft.
<br /> 3. Gonsrstor's Certifleation: 01 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, an
<br /> are in all respects in proper ondition for time according to applicable International and national go ental re ions.." ti
<br /> ild/in?-' -'
<br /> Print Nan ` SI &tura Dais/
<br /> 4. TRANSPOggTER ,1 ADgqRESS: Phone N: -
<br /> titenCyCte , InC . This is a Through Shipment Applicable Permit Numbers;
<br /> 7875 R A Bridgeford Rd , TS/OST 80
<br /> Stockton , CA 95206
<br /> a a TRANSPORTERSX2TIFICAT10NA ipt of medical waste as described .
<br /> 1
<br /> Pdnt/Type Name ��- 1 Signature lie
<br /> L am" DBTey tO r �����
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone N:
<br /> N Applicable Permit Numbers;
<br /> I
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> PrinVType Name Signature Date
<br /> Be INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATIQNRecetpt of medical waste as described above,
<br /> Print/T'ype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A. OWIlnr tedd FacN 88. Attamate Facility: q E] 8c, Akamate FacNity: rl 8D. AHernata Faculty:
<br /> eno clave) Stericycle , Inc . (incinerator) Sterioyole , Inc . (Autoclave) Covanta Harlon , Inc
<br /> v 7875AUIXn9WMV*aM1VnRdm 90 N . Foxboro Drive 2775 E . 26th St, 4 $50 Brooklake Road NE
<br /> Stockton , CA 95208 North Salt Lake , UT 84064 Vernon , CA 90058 Brooks, OR 97306
<br /> Z ;•(20=11� 4j 2022 (801 )938- 9171 (888 )788 -7422 (605 )393-08g0
<br /> Lu
<br /> 'T81 0 3A-44 G31JA-38 Pe rrrit * 3534
<br /> Q
<br /> W TREA T F Icy that I ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> i— receivX a ccordance with the requirement outlined In that authorization.
<br /> Pdnveype Name Signature pate
<br />
|