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s MEDICAL WASTE TRACKING FORM NUMBER
<br />0041 St@PiCyCf@' I E OF EMERGENCY CONTACT: CNEMTREC 180042 STANDARD MANIFEST 001 -10 -06 -STD
<br />"° r°"k. W R e 9; 135 - 5 cusmMER NO. 21 AW MDFROOJVEX
<br />1 rans1wrom _ f -1 CU A to ,
<br />1. Generator's Name, Address and Telephone Number UNION
<br />Ins ME
<br />ATTN.John Menaugh �
<br />DOCTORS HOSPITAL Or t?"Ip VMC.A
<br />1205 E WORTH ST
<br />MAWrECA, CA 95336- 4932
<br />(209) 823-3111
<br />11/9/2017
<br />CUMMER NUMBER 6018849-002 GEmERA7ows REoISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO, OF
<br />20. VOLUME
<br />6.2, PG ,Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />T905 - 4O tial Tub (Bio) (5.3 Cit ft'
<br />CONTAINERS
<br />Cu Ft.
<br />,Regulated Medical Waste, n.o.s.,
<br />TB49 — 37 Gal Tub (Dio) (4. 9 Cu It)
<br />6.2
<br />6.2, PG
<br />, PGII
<br />Cu Ft.
<br />®
<br />6 2, PGII Regulated Medical Waste, n.o.s.,
<br />TB14 — 44 Gal Tub (Bio) (5. Cu tt)
<br />, ' Cu Ft
<br />4
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T821— (82 fTP (Fath) f 15— (Chemo) 20 Gal Tub (2.7CUFT)
<br />/]
<br />6.2, PGII
<br />G Cu Ft.
<br />W
<br />Z
<br />,Regulated Medical Waste, n.o.s.,
<br />UIB31- (Bio) /MP31- (Path) I 31- (Chemo) 31 GaTu
<br />Gal b (4.14CUPT
<br />6.2 6.2, PG
<br />, PGII
<br />Cu Ft.
<br />a
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />WB43- (Bio) /PK63- (Path)/ 43- (Chemo) Gal Tub(5.7CUFT)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KRB - Biosystems Cardboard Box (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 />Cu F.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper cqpEftn for transp acco 'ng to appl%cable international and national gov!.rhgieaI&1I regulations'
<br />X—!
<br />L�1-7
<br />Printed/T ped Name Si nature
<br />Date
<br />4. TRANSPORTER i ADDRE S:
<br />Phone #: (866)7B3-7422
<br />W
<br />SteriCycle, Inc. s is a Through Shipment
<br />Applicable Permit Numbers:
<br />6
<br />4135 X. Swift Ave
<br />Hauler Reg# 3400
<br />S a.
<br />Fcesno,CA 93722
<br />a a
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descn
<br />lf )Ci IF
<br />Printlrype Name �Jf (�1L Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />n
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modicat waste as described above.
<br />Print/Typo Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />ig -
<br />�
<br />Applicable Permit Numbers:
<br />m a
<br />z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />}
<br />Designated Facility: 88. Alternato Facility: 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />ri4yCIB. Inc. Inc. Sbe IftC.
<br />, 6m
<br />U
<br />4138 W. SWR Ave 90 N. OXbOlID Drive 1551
<br />RECEIVED
<br />Fresno.CA 83722 North Snit Lake. U7 Hollister. G0. 95023
<br />(w6) mm (ON)7t33-7422 (%6)783-7422
<br />W
<br />TSIOST22 8-, 36 Tsfosr $�
<br />NOV 2 4 2017
<br />NOY 9 x'17
<br />W
<br />TREATMENT FACILITY: i certify that I have been authorized by the applicable state agency to accept untreated a1&0k S*0Ltt* ire
<br />Imo—
<br />received the abo&Uwastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />1 rans1wrom _ f -1 CU A to ,
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