Laserfiche WebLink
MEDICAL WASTE TRACKING FORM NUMBER <br />• • y aA STANDARD MANIFEST 001 -10.06 -STD <br />O ®® Stericycle *SE OF EMERGENCY CONTACT: CHEM rREC 1.800-024 <br />®® Protecting People PRudng Rbk:Route:; 135 - 7 CUSTOMER NO. 21132 <br />1. Generator's Name, Address and Telephone Number <br />AIMN:John Menaugh <br />DOCTORS HOSPITAL OF MAMZCA <br />1205 P, NORTH ST <br />MANTECA, CA 95336- 4932 <br />209 823-3111 10/12/2017 <br />I <br />CUSTOMER NUMBERGENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 28• .. CONTAiNERTYPE 2C. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o a., CONTAINERS <br />6.2, PGII Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s , <br />6 2, PGII 37 <br />Al Tub Rio 4.9 Cu ft Cu Ft. <br />X UN3291, Regufated Madicat Waste, n.o.s., <br />i Q6.2, PGII •. MIA)5.9 CU ft Cu Ft <br />UN3291, Regulated Medical Waste, n.o,s., <br />6.2, PGII Ta21-{STQ} TP15 (Path)/ 15- (Chrato)20 +3a] Ttsb(2.7CUFT) 2 • Cu Ft <br />t�LI UN3291 Regulated Medical Waste, n.o.s., <br />W 6,2, PGI) titB31- Bio UP31- !Path ftnl'C31- Chemo 31 Gal Tub 4.14CUFT Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s„ <br />6.2, PGII WR6r Cu Ft. <br />UN3291 Regulated Medical Waste, n.a s„ <br />6.2, PGII _ai Cu Ft. <br />UN3291 Regulated Medical Waste, n o.s., <br />6.2. PGII Cu Ft <br />i UN3291, Regulated Medical Waste, n.o s., _ <br />3. Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately I TOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />1l <br />PrintedrTyped Name Signature <br />CC 4. TRANSPORTER 1 ADDRES : <br />y iw- Stericycle, Inc. hia is a Thso gh shipment: <br />a o 4135 W. Swift Ave <br />CL Frealno CA 93722 <br />TRANSPORTER CERT146ATION: Receipt of medical waste as deserib above. <br />N <br />Print/'fype Name frAL Signature <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS' <br />0 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnMpe Name Signature <br />kiI .01 <br />Date — <br />Phone #: pp56 8 7422 <br />Appllcablr� Pe� NumJers. <br />Hauler Reg* 3400 <br />Date I G' rk' 1� I --k <br />Phone #. <br />Applicable Permit Numbers: <br />Date <br />r, 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />�aaa a Applicable Permit Numbers: <br />COILd 0 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />fE- PrinVType Name Signature Dale <br />7. DISCREPANCY INDICATION ar <br />} z A. Designated Facility: 5rAtternate Facility. ❑ 8C. Alternate Facility: ❑ 8D. Altemtyt� f�iFi"T 0 2017 <br />FU- � stere t Stericycle, Inc. Sterlcycle, Inc. tj�+ j /a lr 1 <br />a 4195 90 N. F*Xb*M DAN* 1561 ShOltan Orto J ACQU E WILSON <br />Fresno,CA 83722 North Salt Lake. LIT 84 HollIster. CA 95023 <br />�eaa 41t 2017 (88s)7M?422 (sus)IM7422 <br />W If <br />3A -448,%W36 T5lOST 83 <br />TREATMENT Atkffcertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />t- received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br />PrinMpe Name Signature Date <br />Transferred crrrttatners, eu ft to <br />ORIGINAL <br />