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Stericyc lMEDICAL WASTE TRACKING FORM NUMBER
<br /> e' IN CASE OF EMERGENCY CONTACT: CNEMTREC 1 .800424.0300 STANDARD MANIFEST 001 .03.2loNOCA
<br /> Route #: 703 A 6 CUSTOMER No, 21132 MDTK00129P
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATDIAEricc=DAVIy
<br /> TOKAY DfALYSIS-DAVtTA #2018
<br /> 312 S f"AIRMONTAVE 10/2512022
<br /> LODI , CA 95240-3340 (205) 369-5413
<br /> �ap53; 03- 00 `1
<br /> CUSTOMER NUMBER GENERATOR's REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C, NO, OF 20. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., TB14- ( Btta) TP14-(Path) TY14 - (Inclnerate) 44 Gal . Tub ( . go►� INERs
<br /> 6,21 PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., 0" J at . U t�U
<br /> 6.21 PGII Cu Ft.
<br /> Q UN3291 , Regulated Medical Waste, n.o.s., T I J Brno - t nGl t? fd t? u 7 juttoji
<br /> 0 6.2, PGII I Cu FI,
<br /> UN3291 Regulated Medical Waste, n.os„ r Ie rI a- 0 1 , as , IS
<br /> cc 62, PGII I Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s„ 1 'kR ( ffiwu5 (4 , 802 eaft .)
<br /> Z 8.2, PGI {
<br /> LLJ
<br /> Cu Ff.
<br /> UN3291 Regulated Medical Waste, n•o,s,,
<br /> 621 PGII Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.21 PGII Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s„
<br /> 6.2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n.o,s„
<br /> 6.2, PGII u Ft.
<br /> 3. Generator's Certifleation ; "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 condition for transport according to applicable International and national governmental regulations"
<br /> PX Prl ' N S nature
<br /> 4. TRANSP 115 IS H OU [� `J Ipt11Ot1 Phone N;
<br /> 7375 R A f�ndyeforci Rd .C Applicable Perl�it`�i�4i>b,Inmost (h
<br /> : 30 Stockton , CA 95208
<br /> CL
<br /> IE a TRANSPORTER C IFICAT ON : Receipt of medical waste as desk s
<br /> r t �Z;d, 8. ldtPrini/fype Name ` L2 Signature 2 Date
<br /> NIIIIIIIN
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone R;
<br /> a Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PdnVType Name Signature Date
<br /> n 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS; Phone N;
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> tarinfols IAV Q nIRE
<br /> r.
<br /> in'r�g ord Rd , �U (V . FOx O of live r "tathF � , - a '�r00 13k2 oad PIE
<br /> Stockton , CA 95206 North Salt Lake , LIT 84064 Vernon , CA 90458 Brooke, OR 97305
<br /> U12 14 4 lm A -ELISE (80 `1 )936" 1171 (866)783. 7427 (50'6)^393. 0890
<br /> TS1OSl= LEo, 8AA481JA-88 Pemmit # 304
<br /> w AUTOCLAVED
<br /> TRL'.*MER JACILITY: certify that ! have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> F received the above indicated wastes in accordance with the requirement outlined In that authorization.
<br /> PrinUTyA Signature Date
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