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MEDICAL WASTE TRACKING FORM NUMBER
<br /> �i i• Stericycle` IN CASfpgF jfENy* %T: CHEMTREC 1 -800-424.9300 �O ( T 00i •03.21 •NOCA
<br /> 1 ` �+ CUSTOMER NO, 21132
<br /> 1 . Generat9r!s, Name.EricLWI'YYIBy d Telephone Number
<br /> TOKAY DIALYSIS-DAVITA 12016
<br /> 312 S 1"AIRMONTAVE 2/25/2022
<br /> LODi , C'A95240-3840 ( 209) 359-5418
<br /> 6053303- 001
<br /> CUSTOMEn NUMBER GENERATOR'S REGISTRATION # Tom
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 20. NO. OF 213. VOLUME
<br /> UN3291 , Regulated Medical Waste, n,o,s., T1314 -(133o )mm, i4-( Path ) TY14-( incinerate ) 44 Gal . Tub
<br /> 6,21 PGIi Ik Cu Fl.
<br /> UN3291 Regulated Medical Waste, n.o,s., - ID ,�, ,,� emo a . U U
<br /> 621 PGII Cu FI.
<br /> M UN3291 Regulated Medical Waste, n.o,s„ to et' o ndnera e ).3 7 (jai . 165 (4 . 9 culat. )
<br /> p 6.2, PGII Cu Ft.
<br /> Q UN3291 Regulated Medical Waste, n,o.s., fo err► O atm a . U U
<br /> cc 621 PGIi Cu Ft.
<br /> W UN3291 , Regulated Medical Waste, n.o.s., ID) QaI . orTUga 8 ox Cuff. )
<br /> IZ 6.2, PGII Cu Fl.
<br /> 6 NP329G111 Regulated Medical Waste, n.o.s.,
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<br /> UN3291 Regulated Medical Waste, n.o,s.,
<br /> 6.2, PGII Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s., Cu Ft.
<br /> 6.2, PGII
<br /> UN3291 , Regulated 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 ► ! 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 ulatlons."
<br /> Printed(fyped Name C 004? Signature `L S ' Z TORONTO
<br /> 4. TRANUEl33L1�9wis: Phone #:
<br /> 7575 R A BridgBliOrd Rd . ❑ This is a Through S ' ment Applicable Perm aM f -80
<br /> a°. Stockton, CA 95206 t
<br /> rn
<br /> a Q TRANSPORTERC�E"FICATI , I ' Receipt of medical waste as descri bove. n
<br /> ~ Print/iypeName �IVQr1 t » ti� Signature '�G I ►!l - Date d4 /
<br /> b. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> W Applicable Permit Numbers:
<br /> � 255
<br /> s INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION ' Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> n 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> w !j
<br /> a
<br /> UINTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION ' Receipt of medical waste as described above.
<br /> Z
<br /> Tam PrinVType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> F
<br /> A. Designated FacIN Alternate Facility: nn 8C. Alternate Facility: 8D. Alternate Facility:
<br /> J o e ; {rin E Stec Vole , Inc . (indinetatar) Stedoyole , inc (Autoolave) ovanta Marion , Inc
<br /> 4 875 RA !frairle,
<br /> od 90 N Foxboro Drive 2776 E. 26th St 4850 6rooklake Road NE
<br /> tookton , GA 9 s&L. A No Salt Lake , UT 84054 Vernon , GA 80068 Brooks, OR 97305
<br /> Z $ 209 )294 -7114 (801 936- 1171 (866 )783-7422 : '(505 )393 -0690
<br /> W siosTm JAN 2 6 2022 3A 8/JA-3t3 Permit # 384
<br /> � :s
<br /> Ir REATME4TFACT I that I hav been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> F- r celved the *We Ems in accc rdance with the requirement outlined in that authorization.
<br /> Pn'of yype'Name Signature Date
<br /> ORIGINAL
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