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dh MEDICAL WASTE TRACKING FORM NUMBER <br />®• O <br />ISSE OF EMERGENCY CONTACT: CHEMTREC 1.800424-9 STANDARD MANIFEST 0001.10-MSTD <br />StQi"(CyC'Q° <br />®•® Pmt.nlnyhupi..9.dudnga1 Route #.- 135 — 8 CUSTOMER NO. 21132 <br />1. Generator's Name, Address and Telephone Number II !! I I I <br />AT`€'N a John Menaugh <br />DOCTORS HOSPITAL OF NAVMCA <br />1208 L NORTH. ST <br />MANTECA, CA 95336— 4932 <br />7. DISCREPANCY INDICATION <br />��_Peatgnatea Facility; U 88. Alternate Facility: U 8C. Alternate Facility: U 80.Altemate Facility: <br />St daycle. Inc. Stericycle, Inc. Stedcale, Inc. <br />4136 W. vis 90 N. Foxboro Drive 1851 Shethon Drive <br />1=resno.C:A �Nr+IE %JKtl.. Notch Salt take. Ur 84054 Holll(ater. CA 95023 <br />(866)783.7422 (886)783-7422 (866)783»7422 <br />7WOST2NUV 02 2017 T48 -j"6 -rsf=83 <br />TREATMENT FACILI : i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />received the above UWAft4ailtaistes in accordance with the requirement outlined In that authorization. <br />Print/Tvns Name Sinnaltim nnte <br />Transferred eonta€hers, CU tt to <br />ORIGINAL <br />(209) 823-3111 <br />11/2/2017 <br />CUSTOMER NUMBER 6 rQ) I A 49-002 GENERATOR'S REGISTRATION <br />2A. DESCRIPTION OF WASTE <br />213• CONTAiNERTYPE <br />2C. NO. OF <br />213. VOLUME <br />UN3291Regulated Medical Waste, n.0.s., <br />CONTAINERS <br />6.2, PGII: <br />THOS — 40 Gal `Crib Bio (5.3 cu ft <br />Cu Ft. <br />6 23PGI}91 Regulated Medical Waste, n,o.s., <br />T049 — 37 Gal Tub (Bio) (4.9 cu ft) <br />Cu Ft. <br />X <br />6 23291, Regulated Medical Waste, n.o.s., <br />Q <br />TH14 44 Gal Tub rlo) (5. 9 Cu ft) <br />Cu Ft. <br />UN3291 Regulated MedicalWaste, n.0s., <br />6. 2, 13131190823— <br />(8Iq) /T915— !Fat h) /TY15— (chemo) 20 Gal Tuts (2.70[rlrT) <br />Cu Ft <br />W <br />UN3291 Regulated Medical Waste, n.o.s., <br />+ <br />6.2, PGiI <br />WB31w Bio /WP31— Patti /WC31-- (Chemo) 31 Gal Tub A.14CUF"i' <br />Cu Ft <br />tZ <br />UN3291 Regulated Medical Waste, n.o.s„ <br />6.21PGI I <br />— Chem till 5.7cUPT - <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.0.s„ <br />6.2, PGIIBox <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, 131311 <br />Cu R <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately®�A�S , <br />Cu Ft <br />described above by tho proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />are In all respects in proper condition for transport 5ccording to applicable International and national governmental regu s:' <br />�- <br />Printed/Typed Name Signature <br />Date <br />4. TRANSPORTER i ADDRESS: <br />° <br />Phone #. tR6�� 783-7422 <br />eriCycle T C. s is a T sigh S pment <br />Applicable Permit Numbers: <br />a � <br />a W. S i Ave <br />Hauler Reg# 3400 <br />to <br />t;esno, C 9 22 ^ <br />a <br />TRANSPORT CERTIFIC iO R t aalcat waste as descnb <br />PdnUlype Name agnature <br />Date <br />6. INTERMEDIATE HANDLER 2171RANSPORTER 2 ADDRESS: <br />Phon #: <br />N <br />Applicable Permit Numbers - <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descrbed above. <br />Print/iype Name Signature <br />Data <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />o <br />Applicable Permd Numbers: <br />tu <br />a'A x <br />2p <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />0 <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />��_Peatgnatea Facility; U 88. Alternate Facility: U 8C. Alternate Facility: U 80.Altemate Facility: <br />St daycle. Inc. Stericycle, Inc. Stedcale, Inc. <br />4136 W. vis 90 N. Foxboro Drive 1851 Shethon Drive <br />1=resno.C:A �Nr+IE %JKtl.. Notch Salt take. Ur 84054 Holll(ater. CA 95023 <br />(866)783.7422 (886)783-7422 (866)783»7422 <br />7WOST2NUV 02 2017 T48 -j"6 -rsf=83 <br />TREATMENT FACILI : i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />received the above UWAft4ailtaistes in accordance with the requirement outlined In that authorization. <br />Print/Tvns Name Sinnaltim nnte <br />Transferred eonta€hers, CU tt to <br />ORIGINAL <br />