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4°n Ste69Cycle, <br />00 <br />h -dating vea*. RWU&M III& - <br />MEDICAL WASTE TRACKING FORM NUMBER <br />E OF EMERGENCY CONTACT: CHEMTR€C 1-801}-424 STANDARD MANIFEST 001 -10 -06 -STD <br />to #: 135 - 2 CUSTOMER NO. 2qW MDFROOJVEI <br />c ; _ _ a Tr�mflfe ` R to <br />•.p4' <br />1. Generator's Name, Address and Telephone Number <br />-ATTW:John NMenaugh <br />DOCTORS HOSPITAL O1? MAV=R <br />1205 E NOR'T'H. ST <br />MANTwA, CA 95336— 4932 <br />(209) 823=3111. <br />11/16/2017 <br />CUSTDMER NUMBER 6018 g 49-002 GENERATOR'S REGISTRATION If <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n•o.s., <br />CONTAINERS <br />6.2. PGII <br />TB05 - 40 tial rub (Bio) (5.3 cu tt) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, o.o.s.. <br />6.2, PGII <br />TB49 - 37 tial Tub (Bio) (4.9 Cu tt) <br />Cu Ft. <br />® <br />623PG1� Regulated Medical Waste, <br />TB14 - 44 Gal Tub (Dio) (3.9 cu tt) <br />Cu FL <br />UN3291, Regulated Medical Waste, n•o.s., <br />TB21- (BI SP1 (Path) / 15- (Chemo) 20 Gal Tub (2.743M) <br />6.2, PGII <br />Cu Ft. <br />W <br />Z <br />UN3291, Regulated Medical Waste, mo -s., <br />6.2, PGII <br />U931- (Bio) /WP31- (Path) / 31- (Chemo) 31 tial Tub (4.14CUFT <br />Cu Ft. <br />Lu <br />Regulated Medical Waste, n•o.s.. <br />6.2, P61 i <br />11843- (Bio) /PK43- (Path)1 3- (Cheno) tial Tub (5.7CUFT) <br />Cu Ft <br />I <br />UN3291, Regulated Medical Waste, <br />6.2, PGII <br />KRB - Biosystems Cardboard Box (4.2 cu ft) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, 0.0.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, o.o.s., <br />6.2, PGII <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurst T®TA ® <br />c� <br />J 1Ij j . T Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/pla an <br />are in all respects in proper n n for tranf/BP�o/tjaccord' g to app' t I/�/e/�/lntemational and national ve men regulatio s <br />Ij " <br />XPrinted/Typed <br />Name " v ° signature <br />Date <br />� <br />4. TRANSPORTER 1 ADDRESS. '1 <br />Phone #: <br />(866) 785-7422 <br />Stericwle, Inc. T s is a Through shipment <br />Appiicable Permit Numbers: <br />IM4135 <br />a O <br />S. Swift Ave <br />Hauler Reg# 3400 <br />2 N <br />If <br />Freano,CA 93722 <br />Z <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as desenbecLabove. <br />Print/Type Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers: <br />w� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />1= <br />Print(rype Name Signature <br />Date <br />t:, W <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />a <br />Applicable Permit Numbers: <br />Ic <br />LIJI <br />e <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />y <br />F- <br />Print(rype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />$p <br />gnated Facility: 8& Alternate Facility: 8C. Akernaie Facility: <br />El BD. Alternate Facility: <br />v <br />Q <br />Sterityde. Inc. ftr4,de, Inc. <br />4135 W. SANt AV$ 90 N. F06M Orin 1551 sheftn On" RECEIVED <br />Fresno CA 93724 NOM Sal LAM, UT . CA 95M3 <br />(866)78, -7422!WE (616)78'37422 1;866)783.7422 <br />Ts 34448-JAr3e TSKW83 <br />NOV 2 4 2017 <br />aTREATMENT <br />FACILITY Y416y I have been authorized by the applicable state agency to accept untreatedjYA Q peW(LQ_V0 J*ve <br />F- <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name �' f Signature <br />Date <br />c ; _ _ a Tr�mflfe ` R to <br />•.p4' <br />