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— MEDICAL WASTETRACKING FORM NUMBER
<br /> i� Stencycles IN CASE OF EMERGENCY CONTACT: CHEMTREC i •8004124.9300 STANDARD MANIFESTo01 •03v21 •NOCA
<br /> Route #f: 706 - 2 CUSTOMER NO. 21132 MDTKOOOH27
<br /> I 1 . Generator's Name, Address and Telephone Number
<br /> ATTI`J : lyric tsrnvdey III111111illIIHIIIII III III
<br /> TaKA�` GIALYBi a- DAVITA #20 't G
<br /> 312 S FAIRMONT AVE 3l2512G22
<br /> LOD17 CAu'5240-3840 ( 209) 36M418
<br /> 0053310MG1
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION III
<br /> 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO* OF 2D, VOLUME
<br /> UN3291 , Regulated Medical waste, n,o,s., TB14 -(Blo ) I P14-( Path ) TY `I4 -0 noinerat>e } 44 G81 . Tub eO TLIV
<br /> 62, PGII N Trz[ }) , Cu Ft.
<br /> 623 PGI € RegulatedMedfcai Waste, n.o.s., TB21 - (Blo )._TP15- ( Path )-,.,_.TY '15-( Chemo ) _,,,,, 20 GaI . TUb (2.7 Cult . ) Cu Ft.
<br /> O UUN32P91 Regulated Medical Waste, n.o.s. , TE� Q_ (Bio ) TY40_(Cherria ) T148-( incinerate ) 27 Gal (4 .10Cuft. )
<br /> Cu Ft.
<br /> IN
<br /> 623 PGII Regulated Medical Waste, n,o.s„ Vb843-( Bio ) C1i� U Chemo ) .WX4 ( Phawn ) 43 Gal * ( 5 . 7Cr1ft . ) Cu Ft.
<br /> LU Z 623P611Regulated Medical Waste, n,o.s., €{ R (Bio ) Gal . Cormigated Box (x , 32 1 fi. )
<br /> Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s., [['
<br /> 6,2, PGII GAvV000AQXCI o ti t3 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 /> 6.2, PGII Ou Ft.
<br /> UN3291 Regulated Medical Waste, n.os.,
<br /> 6.2, PGIi Cu Ft.
<br /> 3. Generator's Certifications 'I hereby declare that the contents of this consignment are fully and accurately TOTALS 161 6 Cu Flo
<br /> described above by the proper shlppping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In all respects In proper coryditlon for transport according to applicable International and national governmental r gulations:'
<br /> Printed/Typed Name Signature Date
<br /> 31
<br /> 4. TRANSPORTER 1 ADDRESS: Phone #: ( �(}� ) 2 �c{ _ Tt}
<br /> °C + t riCyclfu , Inc . This is C ThrOtI, 11 Shil) tr ant Applicable Permit Numbers:
<br /> a 1375 R A Bri1:lgefor�t Rd . TS;/0SOTL; G
<br /> a t7cktr� r� CA .�520 �
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<br /> RE C TRANSPORTER C I ICATIOANDReceipt of medical waste as describe ova. (J 1
<br /> Print/Type Name � Signature fn. W " Date
<br /> o 251. 0,
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> r Applicable Permit Numbers;
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Printrfype Name Signature Date
<br /> 6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #:
<br /> cc Applicable Permit Numbers:
<br /> S INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> x
<br /> Printrrype Name Signature Date
<br /> 7. DISCREPANRf( M1e TII;F
<br /> I GALEA
<br /> AUTOCLAVED
<br /> } , 8A. Designated Facility: 189. ANemate Facility: E] 8C. ANsrnate Facility: 8D. Alternate Facility:
<br /> J BteTiaycleMl� (,`�I �pF�IQ yt tericycle , Inc . (Incinerator) Sterioyole , Inc . (Autoclave) C:okianta l+.tarlon , Inc
<br /> Q
<br /> 11 7575 RA Bridyeford Rd . 0 N . Foxboro Drive 2775 E . 2661 St, 4860 Bruokla€te >z.Iad NG
<br /> E H UatcoNon , CA 95208 € olth Balt i alae , UT 04054 Vernon , C:A 900fi& F�roolts, CSR 97.05
<br /> r Z 'tag (209 ) :MW4 & l7Ce ; ( 00936- 1171 (860 )78; -7422 (505 )893- 0590
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<br /> g s d a A-s118/JA-'3 to I' r r i i t 4 3B`}
<br /> TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br /> fE received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> E PrinVType Name Signature Date
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<br /> - - ORIGiNAL - -
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