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MEDICAL WASTE TRACKING FORM NUMBER <br />Cp Steric cleeOF EMERGENCY CONTACT: CMEMTREC 1-900-42 STANDARD MANIFEST oot-10-06-STD <br />e "emai-IftQde.R Risk t* <br />#: 132 - 1 CUSTOMER NO. 211 JW NDFROOJSf TH <br />1- Generator's Name, Address and Telephone Number <br />AR��N;John MenaugII <br />WCI=S WSPITRI. OE' MA=M <br />1205 E WMTH ST <br />MAWMCA, CA 95336- 4932 <br />(209) 823-3111 <br />11/20/2017 <br />CUSTOMER NUMBER 6018849-002 GENERATOR'S REGISTRATION <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291, Regulated Medical Waste, n.c.s., <br />6.2, PGII <br />TBOS - 40 Gal Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />T849 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />Cu Ft. <br />® <br />623 9111 Regulated Medical Waste, n.o.s., <br />TB14 _ 4 0) (5. Cu ft) <br />l101 <br />t <br />Cu Ft. <br />Q <br />UN3291 Regulated Medical Waste, n.o.s., <br />TI321- IO} P15- (Pa )j 15- (Chemo) 20 Gal Tub(2.7CUFT) <br />M <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />WB31- (Bio - (Path) / 31- (Chemo)31 Gal Tub (4.14CUFT <br />Z <br />6.2, PGII <br />Cu Ft, <br />Regulated Medical Waste, mos.,, <br />6.2. PG <br />6.2, PGII <br />ME43- (Bio) /P1i43- (Path} j 43- (Chemo} sal Tub (5.7CEFT) <br />Cu Ft. <br />fi23 GIII Regulated Medical Waste, n.o.s., <br />>Rs - 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 Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TA LS ® <br />Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />in all respects in proper condition for transport according to applicable international and national governmental gulations." <br />Tare <br />a:' k,w' <br />/ <br />1! 211h 7 <br />Printed/Typed Name Signatur <br />Data <br />4. TRANSPORTER 1 ADDRESS: <br />Stericycle, Inc. T s i3 a ThroLtgh BhlpmeTtt <br />Phone #: (866) 783-7422 <br />Permit Numbers: <br />�u <br />sc <br />4135 V. Swift Ave <br />Applicable <br />Saucer Reg# 3400 <br />Freano,CA 93122 <br />a q <br />TRANSPORLERE RCATION: Receipt of medical waste asPrinVType <br />NamSignal a <br />Date v <br />5. INTERMEDIATE HANDLER A PORTER 2 ADDRESS: <br />Phone C <br />a I`r <br />Applicable Permit Numbers: <br />O <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Data <br />e, <br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: <br />Phone #; <br />Applicable Permit Numbers: <br />ZZ <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 />BA. Designated Facility: . Alternate Facility: 6C. Alternate Faculty: <br />Inc <br />0 6D. Alternate Facility: <br />a <br />4136W.�eSvtA1t Ave SQ N. . Drive 1551 DrWe RECEIVED <br />U. <br />Fresno.CA 537 gNNE North Salt Lalfaa, IJT CA <br />(866)783.7422 (866)783.7422 (866)783"7422 <br />Z <br />U.1 <br />TSIOST22 3A44a�.�a-3s . <br />NOV 2 4 2017 <br />NOV 20 201 « <br />►- <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept unlreate'd <br />received the above indicae+d n accordance with the requirement outlined in that authorization.=~ <br />cJ�t F"WA6&QjAe <br />Print/type Name Signature <br />Date <br />