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00® Stericycl@° <br />®• <br />° ptoteeUny People. Reducing R4f,• <br />i <br />�1 <br />f3: <br />W <br />Z <br />W <br />C7 <br />W <br />w <br />Mo <br />a� <br />M <br />i— <br />MEDICAL WASTE TRACKING FORM NUMBER <br />ISE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-93 STANDARD MANIFEST 001-10-06•S7D <br />'Route #: 132 — 1 CUSTOMER NO. 21132 MDFR00JR01 <br />1. Generator's Natne, Address and Telephone Number <br />A` TN:Jahn Menaugh <br />DOCTORS HOSPITAL OF M WaCA <br />1205 E NORTH ST <br />MANTECA, CA 916336- 4932 <br />(209) 823--3111 <br />I <br />10/9/2017 <br />CUSTOMER NUMBER 6018849--002 GENERATOR'sREGISTRATION# <br />2A. DESCRIPTION OF WASTE 2S• CONTAINERTYPE 2C. NO. OF 21D. VOLUME <br />UN3291 Regulated Medical Waste, n.o,s., TBOS — 40 Gal Tub (Biro) (5.3 Cu ft) CONTAINERS <br />6.2, PGI) Cu Ft <br />UN3291 Regulated Medical Waste, n.o,s., TB49 - 37 Gal Tub (Biro) (4.9 Cu it) <br />6.21 Pali Ft <br />UN3291t Regulated Medical Waste, n.o.s., TB14 - 44 Gal Tub (Bio) (5.9 Cu ft) t <br />—tSTCI]JTP17—tYeLrJlJ1X19—[~:J3e�vl.rtr Jeaa iUMVA.. <br />6.2, <br />UN32og �I Regulated Medical Waste, n.o.s.,I WB31- (Ilio) /WP31- (Fath) /WC31- (Chemo) 31 Gal Tub (4.14CUF'T4 <br />rt„ M <br />UNJZUImegulaieu meaical waste, n.o.s., WB62- (f3io) /EW63— (Path) /Crir43- (Chemo) tial Tub (5.7CUFT) <br />6.2, PH Cu Ft <br />., PG11 Regulated Medical Waste, n.o,s., <br />62 p - Biosystems Cardboard Box (4.2 Cu ft) Cu Ft <br />6,2, PG <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, Pall Cu Ft. <br />623291 Regulated Medical CuF <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurate) TOTALS 0j, <br />described above by the proper s ping name, and are classified, packaged, marked and labelied/plac , and , <br />Ia� re In all respects in proper nditi n for traanssp a%c/�rdfng/t to ap Ilc��bllee%International and national v nmental regu tion (/,/////iy%"/►fI (/� <br />f A tMA..teart:, .A Name 4 r ( ..�//U! �/� / Rin At111P � "r-1 D(, -t, <br />1 AbDR <br />Stericycle, Inc.1 11 Trap is a Through tstl:I.ptaent <br />4135 A. Swift Ave Lfj <br />Freano,CA 93722 <br />1AERVICATION: Receipt of medical waste as described above. <br />Phone #: (866) 783•-742"e <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />�t110 <br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS- <br />Phone #. <br />Applicable Permit Numbers, <br />y <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers <br />H <br />Z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/fype Name --- Signature <br />Date <br />7. DISCREPANCY INDICATION <br />RECEI VED- <br />�g <br />} <br />eA. Designated Faculty: ae. Alternate Facility: ® 8C. Alternate Facility. <br />❑ 8D. Alternate Facility: <br />OCT 12 2017 <br />Wedcyate, Inc. ericyde. Inc. Sterlaycle, Inc. <br />a <br />W. <br />. <br />4135 90 N. Foxboro OrNe 1581 Shobn Drive <br />Fresno% North Salt Lake. UT $40Hotllster. CA 96023 <br />J AC Q U E WILSON <br />((8 X793-7422 (866)783-7422 `866)783-7422 <br />tu If <br />3A -94&.1A 36 TSlGS783 <br />b <br />' <br />Q <br />uu <br />TREATMENT F4r}4Q(jW4ertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above ihdicd wastes in accordance with the- requirement outlined In that authorization. <br />PrinVType Name Signature <br />Date <br />C" <br />sC' <br />• <br />' <br />I <br />ORIGINAL <br />