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MEDICAL WASTE TRACKING FORM NUMBER
<br /> S#ericycle� 1N CASG.QF_ & Efl[iENG Jt{�AGT: CHEMTREG 1 800 424 9300 � �¢,i W'IT 001 •03.21 •N0CA
<br /> pC �1�tt�p $ tCQI![ �F t ua t �5 CUSTOMER NO, 21132
<br /> UUr t
<br /> 1 . Generate I I N4 Cric Crowley
<br /> and Number
<br /> TOKAY DIALYSIS�DAVITA #2016
<br /> ' 312 S FAIRMONTAVE 3/8/2022
<br /> LODI , OA95240- 3840 ( 209) 36M418
<br /> i
<br /> 6053303-001
<br /> CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 2% CONTAINER TYPE 20, NO, OF 213. VOLUME
<br /> UN3291 Regulated Medical Waste, n.o.s., TB14 - (Elio ). &TP14 -(Path) TY14 -( Incinerate ) 44 Cal . Tub "�9�ftR�t
<br /> 6,2, PGII % 1 1Cu Ft.
<br /> UN3291I Regulated Medical Waste, MO.&, 2 - to O- d �_ _ - lema .. aa , IU
<br /> 6.2, PGI
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<br /> I= UN3291 , Regulated Medical Waste, n.o.s., - IO , _ T -(G erno ),_ - nGnera a Gala t t a t . )
<br /> 6.2, PGII , , Cu Ft.
<br /> Q UN3291 Regulated Medical Waste, n.o,s.,
<br /> CC 6.2, PGII Cu Ft.
<br /> W UN3291 Regulated Medical Waste, n.o.s., IO ) .0al , orruga a OX . s Cuff. )
<br /> Z 6,2, PGII Cu Ft.
<br /> LU
<br /> UN3291 Regulated Medical Waste, n ,ox.,
<br /> 6.2, PGII
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<br /> UN3291 Regulated Medical Waste, n,o.s.,
<br /> 6.2, PGiI Cu Ft.
<br /> UN3291 Regulated Medical Waste, n.o.s.,
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<br /> UN3291 , Regulated Medical Waste, n.o.s.,
<br /> 6.2, PGiI Cu Ft.
<br /> 3. Generator's Certification : `I hereby declare that the contents of [his consignment are fully and accurately TOTALS / Cu Ft.
<br /> described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded,
<br /> are in all respects In proper concl ion for transpor ccording to applicable International and national govern a at egulation . '
<br /> Pdntedfr Name
<br /> Signature e
<br /> 4. TRAM Phone # :
<br /> tr W W ,91W 1:1 Thie ie a Tliwlgh Shipti
<br /> 7875 R A Rlidgeford Rd . Applicable Pertr Akwtberer•ao
<br /> < g Stockton , CA 95206 t 'alga
<br /> a < TRANSPORTER CERTiFICAT N• Receipt of medical waste as describ ve. p
<br /> �d
<br /> Printtlype Name `1VOn �� � Signature Date
<br /> 5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> a Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> $
<br /> No a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION : Receipt of medical waste as described above.
<br /> fEc a � =
<br /> PrinttType Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> 8A4 t7eelflnated Facility; 88. Akemate Facility: 8C, Attemate Facility: 80. Alternate Facility:
<br /> J pvs �Altttt�ciia��?e n0ycle , Inc . (incinerator) Stenovole , ino . (Autoclave) Gavanta Marione [ no
<br /> 4 875 fR �[Ydtit� l'fbr FEDI C 80 J . Fnxbaro Drive 277 E . 2tith 5t, 4860 Brooklake Road NE
<br /> U6 Stockton , CAFT6EA No 1 Salt: Lake , UT 84854 Vernon , CA 40058 Brooks, OR 97' 306
<br /> Z i (209)2@44711 ' (8 1 }936- 1971 (866 )7834422Lu
<br /> (585)393- 0820
<br /> TVQST OC MAR 10 2022 3A $f 1A-38 Permit # 364
<br /> d
<br /> u h TREATMENT FACILITY: I certify that I ha a been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> H received ; oval stes in ac ordance with the requirement outlined in that authorization .
<br /> tr4epe Name Signature Date
<br /> ORIGINAL.
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