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ON@ Stericycle° <br />®4® <br />MEDICAL_ WASTE TRACKING FORM NUMBER <br />IWWE OF EMERGeNCY CONTACT: CHEMTREC 1.800-424.9 STANDARD MANIFEST 0011 -10 -06 -STD <br />0: 132 - 2" CUSTOMER NO. 2i MDFR00311T 3 <br />• <br />1. Generator's Name, gTelephone Number � �� � � � � � � � � �i � � • <br />}vAddress <br />{�and <br />ATTN.-John �"�naugh jl <br />DOCTORS HOSPITAL OF NANTECA <br />1205 E NORTH ST <br />•MANTECA, CA 95336- 4932 <br />(209) 823-3111 <br />11/13/2017 <br />CUSTOMER NUMBER 6018849-002 GENERATUR's REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TH05 - 40 Gal Tub (Bio) (5.3 Cu it) <br />CONTAINERS <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu tt) <br />PGII <br />Cu Ft <br />Q <br />UN3291, Regulated Medical Waste, n.o.s.,TBl4 <br />- 4 Gal Tub (Bio) (5.9 Cu ft) <br />/ ®� <br />® <br />6.2, PGII <br />+ Cu Ft <br />Q <br />Regulated Medical Waste, n.o.s., <br />B2 (B ) 15- (Pa ) 1 (Chemo) 20 Gal Tub (2.7CUPT) <br />�- <br />& <br />6U232P`111 <br />. Cu FI <br />W <br />URegulated Medical Waste, n.o.s., <br />6.22,, PGII PGII <br />1- (Bio) /NP31- (Path)! 31- (Chemo) 31 Gal Tub (4.14CUFT <br />Cu Ft <br />' <br />6 23 PGI! Regulated Medical Waste, n.o.s.. <br />116863- (Bio) %PM&2- (Path) / 43- (Chemo) Gal Tt&(5.7CUPT) <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />KRB - Biosystems Cardboard Sox (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 />+ <br />62, PGII <br />Cu FI <br />3. Generator's Certification: "I hereby declare that the contents of this Consignment are fully and accurately TOTALS 10' <br />r -2— If&cf. Cu FI <br />described above by the pr me, and are classified, packaged, marked and Iabelled/placar and <br />are in all respects in er 'tion fort sport a rdin applicable international and national a ental r la s" <br />;Printed/Typed Name Signature <br />Date <br />4. TRANSPORTER i ADD <br />Stec cycle, Inc. U This is a Through Shipmen <br />Phone #: ($66) 7$ -742 <br />Numbers: <br />4135 9. Swift Ave <br />Applicable Permit <br />Hauler Regi 3400 <br />M N <br />Fresno,CA 93722 <br />M Q <br />TRANSPORTER CERTIFICATI N: Receipt of medical waste as described 0 _ <br />j`� <br />00 <br />Print/Type Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />gApplicable <br />Permit Numbers: <br />wo <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone it: <br />cc <br />F < UJI <br />Applicable Permit Numbers: <br />W <br />Old <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: <br />tL <br />z <br />Receipt of medical waste as described above. <br />FPrint/Type <br />Name Signature <br />Date <br />T. DISCREPANCY INDICATION <br />A. Designated Facility: Be. Alternate Facility: ❑ 8C. Alternate Facility: <br />80. Alternate Faculty: <br />Inc. Sterlicti,,de. Inc. <br />S W. <br />v <br />SWIlt Ave 90 N. OOOM <br />41DtNe 1551 Shelton OrIre <br />a <br />Frets North Salt Lalw. Uf 8404 HollIder. CA 85023 <br />(8th) (856)783-7422 ( )?M?422 <br />MOT 911 <br />OV" 13 2017 <br />= iTREATMENT <br />I I certify that I have been authorized by the applicable state agency to accept untr <br />1C,&IGaseate aith <br />I- <br />received thea wastes in accordance with the requirement outlined in that authorization. <br />Print/rype Name Signature <br />Date AI[1U i. 7ne7 <br />}} <br />JACQUE WILSON <br />ONGINAL, <br />