|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> i1PIs � Stericydea IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -600-4249300 STANDARD MANIFEST 001 .03.21 •N0CA
<br /> Route # 703 .9 CUSTOMER NO, 21132 MDTK00113VN
<br /> Mew
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATTN : Eric Crowley
<br /> � �
<br /> TOKAY DlALYSIS-DAVlTA X2016
<br /> 312 3 FAIRMONTAVE 1 /31 /2023
<br /> LODI , CA952411exI ( 209) 369-5416
<br /> CUSTOMERNumsEA 6053303- 001 GENERAT01111REoiISTRATM0
<br /> 2A. DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. Not OF 2D, VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s,, CONTAIN
<br /> 621 PGII TH43( Bio ) TP43( Pa ) TC43 ( Ch ) TX43( Ph ) 43Ca ( 6 e Cu Ft.
<br /> 6 N329Regulated Regulated Medical Waste, n,os„ TH31 ( Bio ) TP31 (Pa )_ TC31 (Ch ),^ TX31 (Ph ) 31 G aIT (4 414 Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o,s„
<br /> p 6,21 PGII KR ( Bin ) RX ( Pharm ) Corrugated Box ( 4 . 3 ) Cu H=Cu
<br /> 623PGII Regulated Medical Waste, n,o.s., R X GAVOT Gasketed Shardill Ip Conte j CuFt )
<br /> W UN3291 Regulated Medical Waste, n.o.s„
<br /> w602, PGd • SH GAUOT Gasketed Sharp Cont . ( CuFt ) Cu Ft.
<br /> 5 UN3291 Regulated Medical Waste, n.o.s.;
<br /> 62, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o,s.,
<br /> 662, PGII t Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGII Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 62, PGII Cu Ft.
<br /> 3. Generator's CertMWIon, "I hereby declare that the contents of this consignment are fully and accurately TOTALS (► 6 a Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labeileWplacarded, and
<br /> are in all respects In proper condition for lranspo according to applicable International and national governmental
<br /> Print Name C SI Data Lod t::h2
<br /> 4* TRANSPORTER 1 ADDRESS; Phone 11: ( 209) 2944114
<br /> ► Stericycle , Inc . This is 13 Throug [rI I3hipment Applicable Permit Numbers:
<br /> 7875 R A Btid eford Rd . MORE To 80
<br /> Stockton , CA 95206
<br /> IRE
<br /> CL TRANSPORTER .0 CATIO • R ipt of medical waste as described a . C� j
<br /> Pdn Name 11 T� � ' d ` 3 '
<br /> t/Type " �^ 1 Signature Data
<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone 8:
<br /> a � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br /> Print/Type Name Signature Date
<br /> 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone C
<br /> cc a Applicable Permit Numbers:
<br /> ry
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of edlcal waste as described above,
<br /> PdnVType Nemo Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> °"�"a eB, AMarnsb FscHky: 6C. Altemala Facility:ED 1113. Altamab Facilky:
<br /> St�erloydW. T" Molave) Steticycle , Ino . (Autoclave ) Stericycle , Inc . (Autoclave) Covanta Marion , Ino
<br /> 7875 RA Bri r�or�, 1551 Shelton Drive 2775 E . 28th Sr, 4850 Brooklake Road I�lF
<br /> 1 tockt,�Ii�4�5kQU Hollister, C.A. 95023 Vernon , CA 90058 Brooks, OR 97305
<br /> w {19 )294 -7114 (868 )783-7422 (886 )7837422 (505 )393-Q89Q
<br /> 05T at74AW sAf0a TSIOST e3 Pe "T it # 384
<br /> T T FACILITY: I certify that I 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 /> Q PrinMpe Name Signature Date
<br /> M
<br /> O
<br /> O
<br /> ORIGINAL
<br />
|