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le <br />*'®• 5tericycle' <br />".lyd.a "w rtd.,ft Rhk: <br />SE OF EMERGENCY CONTACT: CHEMTREC 1-800-424- <br />ta 1>f : 135 - CUSTOMER NO. 210 <br />MEDICAL WASTE TRACKING FORM NUMBE:e <br />STANDARD MANIFEST 001 -10 -06 -STD <br />MDFROOJSIK <br />IV- <br />:-_ 17 <br />.g Trail bffed _ 7-- -,1cuA to <br />1. Generator's Name, Address and Telephone Number notes <br />ATTN : John ' Menaug h <br />DOCTORS HOSPITAL Or MNTECA <br />1205 B WORTH ST <br />MAYMCA, CA 9S336- 4932 <br />(209) 823-3111 <br />10/19/2017 <br />CUSTOMER NUMBER 6018849-002 GENERATOi REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />6.2, PGII <br />TBD5 — 40 Gal Tub (Bio) (5.3 Cu ft? <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu tt) <br />Cu Ft. <br />CC <br />® <br />UN3291, Regulated Medical Waste. n,o.s., <br />6.2, PGII <br />TB14 - 44 Gal Tub(Dio) (5.9 Cu t;t) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />TB21- (HIO TP15 (Pnth) / 1S- (Chemo) 20 Gal Tub (2.7CUFT) <br />Z <br />6.2. PGII <br />T Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, It.o.s., <br />6.2, PGII <br />WB31- (Bio) /VP31- (Path) / 31- 4Chemo) 31 Gal Tub (4. i9Ct1FT <br />Cu Ft <br />IZ <br />623291PGII Regulated Medical Waste,n.o.s., <br />NB03-(aio)/PK63-(Path)/ 63 -(Chemo) Gal Tuit(S_TCUFT} <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />li — Siosystems Cardboard Holt: (4.2 Cu ft) <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 />QuLFI <br />3. Generator's Certlficatlon: "I hereby declare that the contents of this consignment are fully and aocurately TOTALSA <br />Cu Ft <br />described above by the proper hl ing name, and ar classified, packaged, marked and labelled/plrgnmental <br />are in all respects in proper Ilion trans n a or g to applicable ' t tional and national egulatio s <br />ie <br />XPrintedlryped Name VlaSigna re <br />at <br />4. TRANSPORTER 1 ADDRES <br />Phone #: (866) 783, 74 2 <br />StericWle, Inc.This is a Through shipment <br />Applicable Permit Nursers: <br />4135 W. Swift Ave <br />Hauler Rei 3900 <br />20. <br />Fresito,CR 93722 <br />CC a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as desc ' d above <br />cr <br />PrinUType Name ` - Signature <br />Dale 1b 1q <br />S. INTERMEDIATE HANDLER 2 !TRANSPORTER 2 ADDRESS: <br />Phone #: <br />N <br />Applicable Permit Numbers: <br />W <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUType Name Signature <br />Date <br />< <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone #: <br />�1E ¢ <br />Applicable Permit Numbers: <br />& A j <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />A. Designated Facility: Alternate Facility: 8C. Altemate Facility: <br />6D. Alternate Facility: <br />J <br />fJ <br />@r14�(I ENE i]Ri 1.: Inc.Swrilcycle. ft. <br />4135 W. SMR AVr41 SO N. FOAM 1561 Show 0"WftftV <br />E I ED <br />Lake. LIT &M <br />I <br />(W 2017 tW s8ss}�- 47 22 <br />NOV Z 4 2011 <br />TSMP <br />a <br />ACQt1F_ WILSON <br />W <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable State agency to accept untreated mediaww"t6,54Q�that I have <br />H <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />�t <br />PrintfType Name Signature <br />Date <br />IV- <br />:-_ 17 <br />.g Trail bffed _ 7-- -,1cuA to <br />