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MEDICAL WASTE TRACKING FORM NUMBER <br />• • Ster,cyclee0 STANDARD MANIFEST 001.10 -06 -STD <br />®a lia'CASE O EMERGENCY CONTACT: CHEMTR 0-4248 ryn <br />• ProteningPeople kdadmi;Ole' Route �'. 132 — 2 CUSTOMER NO. 21132 MDFROOJQIJ <br />1. Gerierator's Name, Address and Telephone Number <br />ATTN:John Menaugh <br />DOCTORS HOSPITAL OF MANTECA <br />ANEaA 08WR 03336— 4932 <br />(209) 823-3111 <br />6018849-002 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 2B• `L'Ba8 _ 40 611 M (BSO=O TAI 3 Gt1lP'Etj <br />UN3291, Regulated Medical Waste, n.o,s., <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o,s., <br />ii <br />® <br />UN3291, Regulatea Mealcal Waste, n.o,s., <br />6.2, PGII <br />_ <br />i� <br />UN3291, Regulated Medlcal blasts, n.c.s., <br />LJ BD. Aitemato Facility: <br />x <br />6.2, PGII <br />ftrIaot. Ina. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />6.2, PGII <br />90 N. Foxboro Drive <br />UN3291 Regulated Medical Waste, n.o.s., <br />Bim~ <br />Fresn > Of= <br />62, PGII <br />North Salt Lake. LIT 840 <br />UN3291 Regulated Medical Waste, n o s., <br />HERBftosyst: <br />--- <br />(8607(866)7$3.7422 <br />6.2, PGII <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291. Regulated Medical Waste, n.o.s. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and <br />described above by the proper shipping name, and are classified, packaged, marked and labeiled <br />are in all respects In proper goNition for trspor according to applicable international and nation <br />4 <br />i }Printed%ped Narne JA A NASI <br />X 4. TRANSPORTER 1 Cl.e, Inc. I I This :Ls d <br />3-4 <br />ut 4135 W. Swift Ave <br />a o F>resno,CA 93722 <br />�a <br />rn <br />¢ TRANSPORT R C TI ICATION: Receipt of medical waste as described above. <br />PnnUiboeName tA� Signature d <br />10/2/201.? <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />Phone #: <br />Ap I"t1&P[m%u?#orsj400 <br />Date Cb ,-L". t✓ <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS- Phone N: <br />EI Applicable Permit Numbers, <br />Ni INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />pPrinMpe Name Signature I Date <br />e`a 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS Phone #• <br />W a ¢ Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />[c— PrinVType Name Signature Date <br />7. DfSCREPANGY INDiCA77ON <br />O <br />ff —41 <br />t%iM. Designated Facility: <br />Lf 86. Alternate Facility: <br />u 8C. Alternate Facility: <br />LJ BD. Aitemato Facility: <br />1BtQHq£1@t In, <br />ftrIaot. Ina. <br />suriaycle. Inc. <br />4136 W, SM AW <br />90 N. Foxboro Drive <br />1651 Shelton Drive <br />Fresn > Of= <br />North Salt Lake. LIT 840 <br />Holllster, CA 96023 <br />(8607(866)7$3.7422 <br />t866783-7422 <br />TS/OST22 <br />3A -440 -JA -36 <br />TSIOST 88 <br />OCT o 2 2017 <br />TREATMENT FA ILI% :,l certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the ab %ttE wastes in accordance with the requirement <br />outlined in that authorization. <br />PdnVrype Name <br />Signature <br />Date <br />: <br />o - <br />RI iNAi. <br />Cu Ft. <br />