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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �e00 Stencycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424M930o STANDARD MANIFEST oo1 .03-21 •NOCA
<br /> Route * 703 - 19 CUSTOMER NO, 21132 MDTKOOOCDZ
<br /> 1 . Generator's Name, Address and Telephone Number
<br /> TOKAY DiALYSIS-DAVITA #2016 I
<br /> 312 S FAIRMONTAVE 2 /8/21322
<br /> LOD1 , CA95240= 3840 ( 209) 369-5418
<br /> CUSTOMER NUMBER 6053303-001 GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 20, CONTAINER TYPE 2C. No. OF 20. VOLUME
<br /> UN329i , Regulated Medical Waste, n.o.s., T81a - (sio ) LTP14-( Path ) TY14 -( Incinerate ) as Cal . Tub S�I + u rA t�E C 7
<br /> 6.2, PGII 5 3 . Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„ T821 - (Bio ) ,_7P1 v-(Path ) TY1 &( Cherno ) 20 Gal . TUb (2 .7 Cuft . ) Cu Ft.
<br /> p 62. P9G11� Regulated Medical Waste, n.o.s., 7640- (Bio ) TY40-(Chemo )_ TI49-(Incinerate ) 37 Oat . Tu 2 (a . QCt.lit . )
<br /> Cu Ft.
<br /> cc 623PG9iliRegulaledMediealWagte, n.o.s., `Ar343-(Bio ) CVA3-(Chemo ) VdX43-(Pharrn ) a3 Gal . TLI 3 ( 5 . 7Cuft . )
<br /> Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s., KR.(81o ) Cal . CorRt aced Box 4 . 3? Cult .
<br /> IZ 6,2, PGII ( ) ' g ( ) Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o.s.,
<br /> 6.21 PGII Cu Ft.
<br /> UN3291 , Regulated Medical Waste, n,o.s.,
<br /> 6.21 PGII Cu Ft.
<br /> UNS291 Regulated Medical Waste, n.o.s„
<br /> 6,2 , PGI) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,os.,
<br /> 6.2, PGII Cu Ft.
<br /> 14141401141141
<br /> 3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS ► y7 ♦ 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 /> Printed/Typed Name At,)" Signature Date
<br /> 4. TRANSPORTER 1 ADDRESS: Phone #: ( 209) —
<br /> Stericycle , Inc. � This IS a Through Shipment Applicable Permit Numbers:
<br /> a 0 7 $75 R A Dridgeford Rd . TS/OST 80
<br /> 2 °Stockton , CA 95206
<br /> 10001Va oQC TRANSPORTER CERTIFICATION: Receipt of medical waste as describe Volbo �}
<br /> ~ Printltyps Name -=`. ft _ Signature ' _ Data 0 �Q l
<br /> S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> W, 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> w Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> i x
<br /> - Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> OM I •
<br /> 8A. DesignfiW1 68. AltenuNe Facility: [3 8C. ANemats Facility: 80, Altemate Facility:
<br /> $ toric i '�j f tetioycle , Inc . (incinerator) Stericycle , inc . (Autoclave) Covanta Marlon , Inc
<br /> Q 7875 A l3ridgeford Rd. 9 N . Foxboro Drive 2775 E . 26th St, 4850 8roohlake Road NE
<br /> �- StocktonFW �+� 2022 P ordi Sah Lake , UT 84064 Vernon , CA 90058 brooks, OR 97305
<br /> Z (209 )294 - 4 ( 01 )938 - 1171 (880 )783-7422 (505 ) $93-0890
<br /> k TS/OST-80 3448/JF,-36 Pen7iit # 364
<br /> � '�y�a.
<br /> Ulf TREATMEirIT FA I I certify that I ve been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> !- in accordance with the requirement outlined in that authorization.
<br /> Print/iype Name Signature Dale
<br /> MOURN
<br /> ORIGINAL
<br />
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