|
MEDICAL WASTE TRACKING FORM NUMBER
<br /> 000� Stencycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800-424.9300 STANDARD MANIFEST001 •o3.21 •N00A
<br /> ROUte # 703 _ l l CUSTOMER NO. 21132 MDTK000D2S
<br /> I . Generator's Name, Address and Telephone Number ff II ff ii ff
<br /> ATTN : Eric Crowley
<br /> �
<br /> TOKAY DIALYSIS-DAVITA #2016
<br /> 312 S EAiRMONTAVE 2/15/2022
<br /> LODI , CA95240-3340 ( 209) ?+ 65-54 '€ 3
<br /> I
<br /> CUSTOMER NUMBER GENERATOR'$ REGISTRATION M
<br /> 2A, DESCRIPTION OF WASTE 20• CONTAINER TYPE 20. Not OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o,s„ CONTA N
<br /> 6.2, PGI) TE14- (8ia ) TP14 -( Path ) T114 -( Incinerate ) 44 Gal . Tub ( 5 . 901 34 Cu FI.
<br /> UN3291 Regulated Medical Waste, n.o.s., T821 - EtiD TPI 5- Path TY9Cherno 20 Gal . Tub 2 7 Cult . )
<br /> 6.2, PGII ( }-- ( ) 5-( ) ( ) Cu Fl .
<br /> UN3291 Regulated Medical Waste,
<br /> 0 TCJ
<br /> 49_ Bio . TY49 rna )-�--CheT14f3-( Incinerate ) (37 Gal • Tu 4 . 9 Cuft.
<br /> (a 6.2, PGII ( ( ) Cu Ft.
<br /> UN3291 Regulated Medical Waste, n,o.s„ V�Ii343 Lia CVV43- r'Ilt' n10 VW43 Phan'rl 43Gal . TLi 6 . 7Cuft . Cu Ft.
<br /> 6.2, PGII "( ) ( -� ) ( ) ( )
<br /> W UN3291 Regulated Medical Waste, n,0,s., KR Eio Gal , Corrugated ated Pax 4 . 32 Gult, Cu Fl,
<br /> Lu
<br /> Z 6.2, PGII ( ) � ( )
<br /> Ve UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGII Cu FL
<br /> UN3291 Regulated Medical Waste, n.o.s.,
<br /> 6,2, PGII 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 /> 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 Inteinatlonal and national governmental regulation "
<br /> Printed/Typed Name L Signature Date '
<br /> 4. TRANSPORTER 1 ADDRESS: Phone #,( 209) 284_ 7 '14
<br /> ¢ ateticti7cl, Ince
<br /> This is a ThraUgh Sh• merit Applicable Permit Numbers:
<br /> 7875 R A 13rldgleford Rd . TS/OST 30
<br /> M a Stockton , CA 55206
<br /> allows
<br /> Z04 TRANSPORTER C FICATION : Receipt of medical waste as descri Vol
<br /> Print/Type Name _ rl �d , ( r1 Signature t fl- �'^ �--� bate v 1
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone k:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above, i
<br /> PrinMpa Name Signature Date l
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone rl:
<br /> Applicable Permit Numbers:
<br /> 2 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> 2111 t
<br /> Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> (
<br /> 8A. : 88, Aftemate Facility: E] 8C. Alternate Facility: ❑ 8D. Alternate Facility:
<br /> S erio cfe no , Utoolave) 5tericycle , Inc . (incinerator) Stericycle , inc . (Autooiave) Covanta Madon , Inc
<br /> 7 ii7d 80 N . Foxboro Drive 2776 E . 26th St, 4850 Brooklake Road NE
<br /> u• St�7 .I jnr-, $�, GA 95200 North Salt Lake , UT 84054 Vernon , CA 80058 Brooks, OR 97305
<br /> Z
<br /> (2p�CjN -711 �' U22 (801 )936- 1171 (806 )783-7422 (505 )383- 0890
<br /> ;t8 TWS780 3A4481JA-36 Perttilt # 394
<br /> L T rq ME4?4VQ1k I certify t iat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H received the above Indicated wastlis In accordance with the requirement outlined in that authorization.
<br /> Print/Typs Name Signature Date
<br /> I
<br /> ORIGINAL,
<br />
|