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stericycle- <br />° pf"ectiol ao* Redudn9 FJ <br />ab W <br />MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424-9300 STANDARD MANIFEST 001 -10.06 -STD <br />Route '#: 132 -1 CUSTOMER NO. 211132 MQFROWUH jl <br />ORIGINAL <br />1. Generator's Name,Address and Telephone Number <br />L <br />Al �rLNeVatlas Menaugh � <br />12111111� <br />DOCTORS HOSPITAL OF MAI=CA <br />1205 E NORTH, ST <br />MA-d7ECA, CA 95335- 4932 <br />(20D) 823-3111 <br />11/6/2017 <br />CusTOMER NUMBERGENERATORS REGISTRAMON # <br />2A. DESCRIPTION OFWASTE <br />213... CONTAINERTYPE <br />2C. NO. OF <br />21D. VOLUME <br />Regulated Medical Waste, n.o,s., <br />6 2, PGi3 <br />fiBQ5 - 40 tial Tub Bio' (5.3 Cu ft) <br />CONTAINERS <br />Cu Ft. <br />UN3201 Regulated Medical Waste, n.o.s,, <br />62, 1`611TB49 <br />- 37 Gal Tub (BiO) (4-9 cul fit) <br />Cu Ft <br />® <br />8 2 Nil Regulated Medical Waste, n,a.s., <br />TB14 •- 44 Gal Tub (Bio) (5.9 Cu it) <br />` <br />t <br />`7 (� Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s , <br />6.2, PGfi <br />TB21- (BIO) /TP15- tL%ath) /TY15- (Chemo) 20 Gal Tub (2.7CUFT) <br />2- <br />Cu Ft. <br />Lu <br />W6.2. <br />UN3291 Regulated Medical Waste, R.o.s., <br />PGII <br />WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUFT <br />Cu Ft. <br />UN3201 Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />W843- (Rio) /PW43- (Path) / 43- (Chemo) Coal Tub (5.7cuFT) <br />Cu Ft. <br />UN3201 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />KRB - Bio stems Cardboard Bax (4.2 Cu ft) <br />Cu Ft. <br />UN320i Regulated Medical Waste, n.o.s., <br />6.2, PGI1 <br />Cu Ft. <br />UN3201 Regulated Medical Waste, n.o.s., <br />6.2, PGli <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the coll@nts of this consignment are fully and accurately TOTAL,S'► <br />��, Cu Ft. <br />described above by the props hipping name a d all d, packaged, marked and labelled/placarded, and <br />are In all respects in proper ion fo trans o appog=alional and national governmental regulations" <br />'I <br />M <br />Printed/iyped Name t Signature <br />,/ pate 0(vh] <br />4.TRANSPORTER 1 ADDRESS; <br />Ph #' (8S6) 783-7 22 <br />W <br />Stericycle, na. This is a Through Shipment <br />Applicable Permit Numbers: <br />rt <br />a o <br />4135 W. Swift Ave <br />Hauler Reg# 3400 <br />Nrresn <br />,CA 93722 <br />oa- a <br />TRANSPORTS CE ATION: Receipt of medical waste as described bo <br />° <br />Print llype Nemo Signature <br />Date <br />S. INTERMEDIATE NANDLER 2 /TRANSPORTER 2 ADDRESS. <br />Phone #. <br />6c4 <br />Applicable Permit Numbers: <br />oo <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/T pe Name Signature <br />Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone #: <br />Appkable Permit Numbers: <br />RH <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />s <br />Pr1nt/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />A, Doslgnatod Facility: 88. Alternsto Facility: ® 8C. Alternate Facility: <br />80 Allomate Facility: <br />ahriQyaiQSri <br />O� 6itartQyate. lila. atadcycle, Inc. <br />u, <br />4135W. 196 90 N. Foxboro D&O 1551 Shelton Drive <br />Fresrto.CA 93722 Nofth Sat imke, UT <br />I . <br />Z <br />8404 Hot 6br. CA 951123 <br />(866)783- (866)783-7422 (866)783-7422 <br />P9 6 <br />TSIOST2 17 <br />SA -440%W36 MOST 83 <br />that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that t have <br />TREATMENT FACIt�fttes <br />j F <br />received the above In accordance with the requirement outlined in that authorization. <br />Print/rype Name Signature <br />Date <br />i <br />Transferred eantaln eu it to <br />ORIGINAL <br />