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: ® Ste ricyciv <br />®� �ftlectIng hopt.. Redabi; Risk. <br />MEDICAL. WASTE TRACKING FORM NUMBER <br />I E OF EMERGENCY CONTACT: CHEMTREG 1-800424-98 STANDARD MANIFEST 001.10.06 -STD <br />Route #:.132 — 2 CUSTOMER NO. 21132 MDFROOJTW5 <br />1. Generator's Name, Address and Telephone Number <br />A N,.-Johfi Menaugh <br />DOCTORS HOSPITAL OF M WMCA <br />1205 E WORTH ST <br />MANTECA, CA 95336- 4932 <br />IIIIIB�II�IIIIBINd1�91WAlIIdN <br />(209) 823-3111 <br />` <br />CUSTOMER NUMBEn 6018849-002 GENERATows REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />29. CONTAINERTYPE <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PGII <br />TBQS — 40 tial. Tub (Bio) (5.3 Cu ft) <br />f <br />fi 3291 Regulated Medical Waste, n.os, <br />rXHl9 — 37 Cal Tub (Bio) (4® 9 cu tt) <br />UN3291, Regulated Medical Waste, n.os., <br />TBl4 - 44 Gal Tub (Bi.or (5. Cu Tt) <br />j ® <br />6.2, PGII <br />E N <br />Q <br />UN3291 Regulated Medical Waste, n.o.s., <br />T921- (Bro) /TPi5- (Path) j ia- (Cheoao) 20 Coal TL:b (2.7CUPT) <br />, <br />6.2, PGII <br />Z <br />� <br />6.2, UN3P91 Regulated Medical Waste, n.o.s., <br />PGII <br />WB31- (Bio) /WP31- (Path)/WC31- (Chemo)31 Gal Tub(4.14CUFT) <br />aUN3291 <br />Regulated Medical Waste, n.o.s., <br />6.2,P0Ii <br />UH63-(Bio)/F*d3-(Path)/ d3 -(Chemo) Gal Tub(5.7CUPT) <br />Regulated Medical Waste, .o.s., <br />e 2P9n <br />, PGII <br />xis - Biosystems Cardboard Box (4.2 cu tt) <br />UN3291, Regulated Medical Waste, n.o s., <br />6.2, PGII <br />03291, 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 govemmental re I tions? <br />s -i <br />1 'Pdntedrryped Name 1'�4�����+^ Signature <br />oi: 4, TRANSPORTER 1 ADDRESS: <br />W St:ericycle, Inc. This is a Through shipment <br />S 4135 W. Swift: Ave <br />2 N Fcesno,CA 93722 <br />o°C. oaf TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />~ Print/type Name Signature <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />N W <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />10/30/2017 <br />2C. NO. OF I2D. VOLUME <br />CONTAINERS <br />Date l U ' S! <br />Phone #:(866) 783-7422 <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />M <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #. <br />a Applicable Permit Numbers: <br />ca INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />— Pdnt/rype Name Signature Date <br />7. DISCREPANCY INDICATION <br />4 <br />e� <br />Z <br />ud <br />;A. Dosignatod Facility: <br />Siericycle, Inc. <br />4186 W. Svirllt AVO <br />Fresno.CA 93722 <br />($%j78 ,tyNE OFirIZ <br />T9t0 <br />88. Alternate Facility: <br />Sberlcycle. Inc. <br />90 N. Foxboro DrNa <br />North Salt Lake, UT 84054 <br />(86&)783.7422 <br />TREATMEWFAC)LI't`Y!"PWrtify that I have been authorized by the <br />received the above indicated wastes In accordance with the requirer <br />Print/rype Name Signature <br />BC. Alternate FacUity: <br />SterIcycle, Inc. <br />1651 Shelton DrNs <br />Ho(llster, CA 95023 <br />(866)7B3-7422 <br />MOTO <br />8D. Alternate Facility: <br />Cu FL <br />Cu Ft. <br />.1-7 <br />icable state agency to accept untreated medical wastes and that I have <br />outlined in that authorization. <br />Transferred containers, ou ft to <br />Date <br />