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IN CASE OF EMERGENCY CONTACT. CHEMTREC 1 -800.424.9300 MEDICAL WASTE TRACKING FORM NUMBER <br /> • • Stericycle` STANDARD MANIFEST00t •03.216NOCA <br /> CUSTOMER N0. 21132 <br /> 1 . Generator's Name, Address and Telephone MAW10 <br /> ATTN : 1=riG Cr4wtey � , <br /> TOKAY DIALYSIS-DAVITA X2018 <br /> 312 S FAIRMCkVTAVE 1 /2012023 <br /> LODI , CA 95240-3840 (209) 3695418 <br /> CUSTOMER NumaER 6305=3X01 GENERATOR'S REofbTRATm ry <br /> 2A. DESCRIP11ONOFWASTE 20• CONTAINER TYPE 2C. No. OF 20. VOLUME <br /> N <br /> 6 23PGI) Regulated Medical Waste, n.os„ CONTAIY . {~} Cu Ft. <br /> 6 23PGIj Regulated Medical Waste, n.o.s., TH31 Bi TP31 Pa TC 1 h TX31 (Phl 31 GalTub 4 11c Cu Ft, <br /> M 6 23PGIj Regulated Medical Waste, n,o.s., <br /> O RX Thard Corr (4 .3) Cu Pt. <br /> Q <br /> 602, PGIj Regulated Medical Waste, n.o.s., RX GAUQT Gasketed Sharp Cont. CUR Cu Ft. <br /> L1C <br /> W UN3291 Regulated Medical Waste, n,o.s., <br /> W 6,2, PGII SH GAL/QT Gasketed Shar Cont. CUFt Cu Ft. <br /> O UN3291 Regulated Medical Waste, n,o.s., <br /> 6.21 PGII Cu Ft. <br /> UN3291 Regulated Medical Waste, n,o.s., <br /> 6.2. PGII t Cu Ft. <br /> UN3291 Regulated Medical Waste, n.o.s„ <br /> 6,2, PGII Cu Ft. <br /> UN32911 Regulated Medical Waste, n.o.s., <br /> 6.24 Cu Ft. <br /> 131311 <br /> 3. Generator's Certiflcatlom "I hereby declare that the contents of this consignment are fully and accurately TOTALS 01� • V 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 governmen a ons" <br /> Print Name & (6 - — s Mtre to <br /> cc 4. TRANSP RTEft 1 A DR SS: rw — <br /> Stencycle , Inc . This is a Through Shipment Applicable arm U be <br /> 7875 R A Bridgeford Rd . T 1 .00 <br /> R Stockton , CA 952116 <br /> a TRANSPORTERS C�B�(1FICATI N: Reoelpt of medical waste as describe I (�� <br /> PrinMpe Name R n Signature ` `-" rL Date dt <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 /> Print/iype Name Signature Date <br /> M 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone N: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of edical waste as described above. <br /> Printqype Name Signature Date <br /> 7. DISCREPANCY INDICATION <br /> 04stg FacI A Facll tIC. F SD. Fa ! <br /> Eericy.�no. irtoctave) te�lcyoe , no. utoclave) enc�7Ac�`e,�ncitoclave) an' "'anon ,`�nr <br /> ej 7976 RA WN#06W#0GALEA 1561 Shelton Drive 2776 E . 28th St, 1860 i3ronklake Road f+lE <br /> �4 Stooldon , CAkOWLAVED Hollister, CA 95023 Vernon , CA 90058 3rooks, OR 97305 <br /> (209)294-7114 (860)783-7422 (866)7834422 505)393- 0890 <br /> TsrasT-an JAN 2 0 2023 Ts(osT�s3Cult ��; <br /> TREATMENT FAr T#fM0 that' l have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above indicated wastes in accordance with the requirement outlined In that authorization. <br /> PrinVryps Name Signature Date <br /> E <br /> ORIGINAL <br />