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<br />%l. Designated Facility: 148L&Aftrernate FecUlty: u BG. Alternate Facility: U 8D. Attsmate Faculty:
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<br />4186 W Nmro t 551 DtNe Y
<br />F North Solt Labe, LITCA 95023
<br />(8M783-7422 (866}783.7422 ( 783-7422
<br />OCT 16 2017 A- 83 NOV 2 4 2017
<br />TREATMENT ILI : I certify that 1 have been authorized by the applicable state agency to accept untreated �tesA tt�� ve
<br />received the led wastes in accordance with the requirement outlined in that authorization.
<br />Printrrype Name ® Signature ,, Date
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<br />MEDICAL WASTE TRACKING FORM NUMBER
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<br />• ®® Stericyde*OF EMERGENCY CONTACT: CHEMTREC 1-800-424-93A& STANDARD MANIFEST 001 -10 -06 -STD
<br />aatenin® Fee. Rik:: CUSTOMER NO. 211W
<br />oW Redu1" I&#: 132 — 2
<br />MDFROOJRYB
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:John Menaugh
<br />DOCTORS HOSPITn CE MVrFCA
<br />1205 E IMTH. ST
<br />IMANTSCA, CA 95336- 4932
<br />(209) 823-3111
<br />1071/16/2017
<br />CUSTOMER NUMBER 6019849-002 GENERATOR,s REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB05 — 40 Gal Tub (Bi®) (5.3 cru ft)
<br />CONTAINERS
<br />6.2. PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T849 - 37 Gal Tub (Bio) (4. 9 Cu t:t)
<br />6.2. PGII
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<br />UU23299111 Regulated Medical Waste, n.o.s.,
<br />TH14 - 44 Gal TOM*) (5.9 Cu TV
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<br />Cu Ft.
<br />QUN3291
<br />Regulated Medical Waste, n.o.s.,
<br />TB21— (8ro) TP1S— (Path} 1S— (Chemo) 20 Gal Tub (2.7CUFT)
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />UB31— (Rio) /UP31- (Path) j 1— (Chemo) 31 Gal Tub (4.14CUFT
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />U1t43- (Hi.o) /P1t03— 4eath) / 43- (Chemo) Gal Tub (5.7CUFT)
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<br />6.2, PG ,Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />IRB — Biosystemz; Cardboard Box (4.2 cu it)
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<br />Cu Ft.
<br />UN3291, Regulated Medical waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 10,
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<br />described above by the proper shipping name, and are classified, packaged, marked and labellecuplacarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental tions"
<br />X-PrintedrNpadNam,
<br />Signature
<br />Date
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<br />4. TRANSPORTER 1 ADDRESS:
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<br />Phone #: (866) 783-7422
<br />SteriC'ycle, Inc. This a Throug $ nt
<br />Applicable Permit Numbers:
<br />4135 V. Swift Ave
<br />Hauler Reg# 3400
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<br />Fresno,CA 93722
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Nam 111"Signature
<br />Date
<br />5. INTERMEDIArg HANDLEPT 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />`"
<br />Appilcable Permit Numbers:
<br />at
<br />NO
<br />NO
<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 />#:
<br />PhoneUJ
<br />LEg w
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-C LU
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<br />Print/Type Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
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<br />%l. Designated Facility: 148L&Aftrernate FecUlty: u BG. Alternate Facility: U 8D. Attsmate Faculty:
<br />17 ,�4C. A1C. 8. E<1C. j�ED
<br />4186 W Nmro t 551 DtNe Y
<br />F North Solt Labe, LITCA 95023
<br />(8M783-7422 (866}783.7422 ( 783-7422
<br />OCT 16 2017 A- 83 NOV 2 4 2017
<br />TREATMENT ILI : I certify that 1 have been authorized by the applicable state agency to accept untreated �tesA tt�� ve
<br />received the led wastes in accordance with the requirement outlined in that authorization.
<br />Printrrype Name ® Signature ,, Date
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<br />
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