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��iti• Stericycle IN CASE OF EMERGENCY CONTACT. CHEMTREC i4W 4244300
<br /> Roule #: 706 -13 CUSTOMER NO. 21132 MDTK081 EF9
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> TOKAY D1 USI ,P• DAVITA #2016
<br /> 312 S FAIRMONT AVE 2/24,12023
<br /> LODI , CA 96240- 3340 (200) 369w5418
<br /> 3053303- 001
<br /> CusToMER NumuR GENERATows RERIsTPATioH
<br /> 2A. DESCRIPTION OF WASTE 261 CONTAINER TYPE 2C, Not OF 20. VOLUME
<br /> UN3291 , Regulated Medical Waste, n.o.s., TH43 (8Irs)K�" ,TP4.3(P3)_ TC43(Ch%l. T143 (Ph),_,4303tTub{5.76C01) CONT RS
<br /> 6*2p PGII 5t a Cu FL
<br /> UN32911 Regulated Medical Waste, n.o.s„ a J....._ ) I ' l 4 ;
<br /> 9.2, PGII Cu Ft.
<br /> IX UNU91 , RaWWW Medial Waste, n.o,s., KR (910) RX ( arm) QorrU rje a OX (
<br /> 0 6.2, PGII aCu Ft.
<br /> UN3291 , RegulotsdMedical Wage, n,o.s., N A UALIr asketed W1ar (.; Onto CSU 4
<br /> 6.2, P011Cu FL
<br /> W UN3291 , Regulated Medical Waste, n.o.s., tattoo070 ! aSKMZI LMVP u Orltv
<br /> z 8.2, PGII Cu Ft.
<br /> Lu
<br /> UN3291 , Regulated Medial Waste, n.o,s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 , Regulated Medial Waste, nm*,
<br /> 8.21 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Mete, n.o.s.,
<br /> 642, PGII Cu Ft.
<br /> UN3291 , Regulebd Medical Waste, n.o.s.,
<br /> 6.21 PGII Cu Ft.
<br /> 3. Generator's Certification : "I hereby declare that the contents of this consignment are fully and accurately TOTALS 11110P (5( eI Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelieci/placarded, and
<br /> aro In all respects In proper oondition for transport according to applicable International and national governmental regulations."
<br /> X Name ag, 54te "� nature 6&2L 23
<br /> 4. TRANS i( Thee is Ph" #
<br /> 7375 R A Biidyefvrd Rd . Appileable Pdr&Qat T*AW
<br /> Stockton , CA 96206 DTSc - Hez waste
<br /> a
<br /> TRANSPORTER MTI I ATIZOF�epipt of medical waste as d 4
<br /> I
<br /> PdnttType Name _ Signature Date
<br /> S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone #:
<br /> ¢N Applicable Permit Numt»ro:
<br /> i
<br /> INTERMEDIATE HANDLER 1 TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> n 0. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phots #: '
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION Transferred (number of containers),
<br /> (cubic feet) to:
<br /> Raw -
<br /> F Facility: Permit TS/OST 26 Designated Facility: Permit TS/OST 154 ❑ Designated Fadl ty: Permit TSIOST-83
<br /> A Stericyde, Inc. l (866) 783-7422 2775 g Stedcycle, Inc. f (866) 7834422 7875 C Stericyde, Inc, 1 (866) 1837422
<br /> East 26th St. RA Brkigeford St. 1551 Shelton Drive
<br /> J Varnori, CA 90658 Stockton, CA 95206 Hollister, CA 95023
<br /> a ❑ Altemate Facility: Permit H15CA ❑ Altemate Facility: Permit 1100001653434 Aftemate Facility,, Permit SIT 60.01
<br /> D Sterlcyde, Inc. 1 (866) 7837422 E Covanta Marion, Inc. / (503) 393�OW F Stericyc4e, Inc ! (886) 7837422
<br /> 3140 N. 7th St 4830 Brookiake Rd, NE 128 Rex Bryan Dr.
<br /> UU Kansas City, KS 66115 Salem, OR 97305 Springhill, LAT1021
<br /> Alternate Facility: Permit 99110103 E] Alternate Faddy: Pemtit # E] Aftemate Faoxty. Permit #
<br /> G Stericyde, Inc. / (866) 783-6188 5815 H Ph# I Pttlk
<br /> Weldon Springs Rd. Address: Address:
<br /> Clinton, IL 61727 Alternate Facility Treatment Date - Place Stamp Above
<br /> Designated Facility: I ce" hart 1 have been authorized by the applicable elate agency to accept untreated /itiX 0�111CM
<br /> medial waste and that I have received IN above indicated waste In accordance with the rewiremml q f1q�
<br /> outlined In that authorization. (Pdnt/Type Name/Sionature/Dats Received a place stamp to the right) FEB 2 7 2023
<br /> ORIGINAL 40 MIS
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