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MEDICAL WASTE; TRACKING FORM NUMBER
<br /> 0e i� Stencycle iN CASE OF EMERGENCY CONTACT: CHEMTREC 1 .600.424.9300 STANDARD MANIFEST001 .03.21•NOCA
<br /> Route #. 706 - 13 CUSTOMER NO, 21132 MDTK0016KL
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> ATEric Crowley
<br /> DI
<br /> T4KAY DIALYSIS- DAVITA #2416
<br /> 312 S FAIRMONTAVE 1 /27/2023
<br /> LODI ) CA95240-3844 ( 209) 369-5# 18
<br /> CUSTOMER NUMBER 605330M01GENERATowa REatsTmTm If
<br /> 2A. DESCRIPTION OF WASTE 2121. CONTAINER TYPE 2C, NO, OF 211D. VOLUME
<br /> CONTAIN
<br /> UN3291 , Regulated Medical Waste, n.a.s., TFW3( Bio ) TP43(Pa ) TC43 ( Ch ) TX43( Ph ) 43Gar U Cu Ft.
<br /> 6.2, PGII
<br /> 613291 Regulated Medical Waste, n,a.s.,611 PGII TH31 1310 TP3 (Pa ). TC31 Ch TX31 Ph 313alT 4 . V Cu Fl,
<br /> CC
<br /> 623PGII Regulated Medical Waste, n.o.s, , KR (Bio ) FAX ( Phartn ) Corrugated Box (4 . 3 )
<br /> F Cu Ft.
<br /> 623PGII Regulated Medical Waste, aa.s.' R X (3AL/QT Gasketed Sharp Cont . j CuFt) Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s. ,
<br /> iZ 6,21 PGII SH GAL/dT Gasketed Sharp Cont . ( CuFt) Cu Ft.
<br /> 0 UN3291 , Regulated Medical Waste, n.a.s,,
<br /> 6.21 PGII Cu Ft,
<br /> UN329i Regulated Medical Waste, n,o.s. ,
<br /> 621 PG{( Cu Ft.
<br /> UN329i Regulated Medical Waste,
<br /> 6,2, PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n.a.s. ,
<br /> 6.21 PGII u Ft.
<br /> 3. Generator's Certification ; of hereby declare that the contents of this consignment are fully and accurately TOTALS ► Q d ,'G_ l Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelied/plaoeud , and
<br /> are In all respects in proper condition for transport according to applicable international and national governmental regulations"
<br /> Print Name +J" - r ` Signature Date `
<br /> 4, TRANSPORTER 1 ADDRESS: Phone #* ( 209) 294-7114
<br /> Stericycle , Inc , This 15 a Through Shipment Applicable Permit Numbers:
<br /> 7875 R A Bridggeferd Rd . TS/OST-80
<br /> Stockton , CA J5206
<br /> o. TRANSPORTER FICATIO �acei t
<br /> of medical waste as descri
<br /> PrnVIrype Name Signature
<br /> Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS; Phone i!:
<br /> N � Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> PrinVrype Name Signature Date
<br /> M 6, INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone ii:
<br /> CC Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION . Receipt of medical waste as described above,
<br /> Print/rype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> , . .
<br /> } YJ BA. Deslpnetsd Facility; 88. Aitsmab Facility: nC, Albmsts Facllky: SD, Rifamate Facility:
<br /> 5 tericya oclave) ' Sterioycle , Inc . (Autoclave) 8terioyele , Inc . (Autoclave) Covanta Clarion , Inc
<br /> ,vq 7875 R ,d . 1551 Shelton Drive 27751x . 28th St, 4850 Brooklake Road NE
<br /> I Stockton , 6 Hollister, CA 95023 Vernon , CA 90058 Brooks, OR 97306
<br /> (209 )2 IJ40 2023 (888 )783-7422 (866 )783 -7422 (605 )393»0890
<br /> Lu
<br /> TSf T5lC1STL63 f'emilttk 364
<br /> pitEATMENTfAAQWV: I certify t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> r olved the above indicated In accordance with the requirement outlined in that authorization .
<br /> d' I Prinitrype Name Signature Date
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<br /> ORIGINAL
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