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• r MEDICAL WASTE TRACKING FORM NUMBER <br />i.6 SjteriCyC1e" WIALS5 O EMERsG,ENCY CONTACT: CHEMTREC 1.800.424-99 STANDARD MANIFEST 001 -10.06 -STD <br />t • ProtectinaPeople.ReducingBilk: Route . 13,E 7 CUSTOMER NO. 21132 MURONOM4 <br />1. Generator's Name, Address and Telephone Number <br />ATTN:John Menaugh <br />j DOCTORS HOSPITAL OF MA=CA <br />jl ME&" B1336- 41.432 <br />(209) 823-3111 10/5/2017 <br />CUSTO6IER NUMBER 6018843-002 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., TH04 — 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br />6 Z PGII Cu R. <br />UN3291, Regulated Medical Waste, n.o.s., G ecu _ <br />® 6 2 pili tteguiatea Meawal waste, n.O.S., LaA'�i — RK lak6t rU" %0.LVF `a. Y •eu c.aer <br />Q U6N32991iI Regulated Medical Waste, n.os., — <br />W UN3291 Regulated Medical Waste, n.o.s., WB — (t3Y o} WP31— (Path)WC31— (Chemo) 31 Gal T d .14CUFT <br />2 6.2, PGII' <br />6UN32P9r�1il;Regulated Medical Waste, n.os., itiBb2- (sio) /pw43- (Path) ! 3- ( Chemo) Gal Tub (5.7CUPT) <br />UN3291 Regulated Medical Waste, n.os., KRB - Biosystems Cardboard Bax (4.2 cu ft) <br />6.2, PGII <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII; <br />UN3291,, Regulated Medical Waste, n.os., <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS ®I <br />described above by the proper shipping name, and are classified, packaged, marked and labellediplacarded, and <br />are in all respects in proper condition for transport according to appitcable international and national governmental eguta fo " <br />I 1Printedrryped Name �" :�°�'' / Signature"fAData <br />4. TRANSPORTER 1 ADDRESS: Phone #: — f 444 <br />IM Stecicycld, Ino. This is a Through shipment Applicable Permit Numbers <br />ri- 4135 W. Swift Ave <br />a a Hauler Regi 3400 <br /><a 0 Frenno,CA 93722 <br />U1 <br />a a TRANSPORTER CERTIFICATION: Receipt of medical waste as des( ed above <br />Print(Type Name wmG QLk i. J� Signature Date a S <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone # <br />pia Applicable Permit Numbers. <br />a� <br />aINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />p <br />PrinMpe Name Signature Date <br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS' Phone #: <br />Va g Applicable Permit Numbers: <br />tu <br />N 21 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />1s <br />— Printfiype Name Signature Date <br />Q <br />� I <br />Lu <br />w, <br />7. DISCREPANCY INDICATION <br />Designated Facility: <br />hrigmlf, Ina. <br />135 W. SMAR <br />Alternate Facility. <br />as le, Ina. <br />N. Foxboro Drive <br />dh Salt Lake. Uir 84054 <br />8C. Attemate Facility: <br />Sharlgcle. ina. <br />1551 Shefton Drive <br />( 66 78r4j95033 <br />TS/OST 83 <br />CEI V <br />J ED. Alternate Facility: <br />OCT 2 0 2017 <br />JACQUE WILSON <br />OCT 05 2091I <br />I f <br />TREATMENT Fcertify that I have been authorized by the ap] ble state agency to accept untreated medical wastes and that I have <br />received the abov 1 A d wastes In accordance with the requirement outlined In that authorization. <br />PrInMpe Name -SignWre Date <br />-- -J�%au Ing 9110 <br />