|
yr a MEDICAL WASTE TRACKING FORM NUMBER
<br />'fF
<br />®®®S
<br />eirecycle" I E OF EMERGENCY CONTACT. CHEMTREC 9-80042493
<br />STANDARD MANIFEST
<br />000
<br />ptotenlnp Peapie, Redudnp Rick: R.tailt:e �: 134 '� '� CUSTOMER N0. 21132
<br />T0071�.10.06•STD
<br />MDF ROO J�rXAA
<br />Stericycle, Inc.
<br />1. Generator's Name, Address and Telephone {Number
<br />4136 W. SWRAVe
<br />i
<br />ATTN:John Menaugh t`
<br />I
<br />PrgNE ORTIZ
<br />DOCTORS HOSPITAL Cf iMA'NTECA
<br />Hollister, CA 95023
<br />>—
<br />1205 E NORTH ST
<br />(866)783-7422
<br />(868)783-7422
<br />MANTECA, CA 95336— 4932
<br />TR14ST22
<br />8Ar4484A-86
<br />(209) 823-3111
<br />11/22/2017
<br />NOV 22 2017
<br />6018849-002
<br />CUSTOMER NUMBER GENERATOR'S REGISTRAMON#
<br />F-
<br />received above
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />Signature
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TBOS _ AO Gal Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
<br />6.2, Pali
<br />Cu Ft.
<br />6.2, PG Regulated Medical Waste, n.ox,,
<br />6.2, PGII
<br />9 ' u (Rio) ( cu
<br />Cu Ft.
<br />IY
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T914 °" 44 Galo cu
<br />Cu Ft.
<br />O
<br />6.2, PGI)
<br />UN3291Regulated Medical Waste, n.o.s.,
<br />Gal
<br />— - "
<br />6.2, PGII
<br />Cu Ft
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />WB — (BIo)WP 1—(Pa ) WC 1— (C emo)Gal T CUFT
<br />6.2, PGIl
<br />Cu Ft
<br />W
<br />32P991, Regulated Medical Waste, n.o.s.,
<br />wB43— (Sia)/pw43— (Path) / 43— (Chemo) Gal Tub (5.7CUFT)
<br />6U2
<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 />6.2,1`13
<br />Regulated Medical Waste, n.o.s,, CI
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS J Ci
<br />described above by the proper shipping name, and are classified, packaged, marked and labelledlplacarded, and
<br />are In all respects In proper congillog for transport accor to applicable international and national govemm 1 ulatlons."
<br />PrintedlTyped Name Y ' Signature Date Y
<br />. p DS: Phone#: —
<br />� ATRANSPORTER 1S�t'RC��gg1G`yOl.e, Inc. This s is a Through Etipment
<br />4135 W. Swift Ave Applicable Permit Numbers,
<br />0 Fcrasno,CA 93722 Hauler: Reg{/ 3400
<br />U)
<br />a TRANSPORT/ER� CERTIFICATION: Receipt of medical waste as desonb
<br />ir
<br />~ Pdnf/Type Namh—tt ,, Slgnaiure Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone M
<br />a Applicable Permit Numbers:
<br />@o
<br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrinMpe Name Signature Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />a INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />rd z
<br />OI= Prinllrype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />............. ..,........."...,, .K...."..
<br />Doelgnated Facility:
<br />80. Alternate Facility: [] 8D. Alternate Facility:
<br />=11 If
<br />Sterlcycle, Inc.
<br />SterIcycle, Inc.
<br />Stericycle, Inc.
<br />oil
<br />4136 W. SWRAVe
<br />90 N. Foxboro Drive
<br />1851 Shelton Drive
<br />w1=reBno,CA
<br />PrgNE ORTIZ
<br />North Safi lake. UT
<br />Hollister, CA 95023
<br />>—
<br />(86&)783-74
<br />(866)783-7422
<br />(868)783-7422
<br />TR14ST22
<br />8Ar4484A-86
<br />TSfOoT83
<br />NOV 22 2017
<br />TREATMENT FACILITX: I certifythat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />the in 4s in In that
<br />F-
<br />received above
<br />accordance with the requirement
<br />outlined authorization.
<br />Print/lype Name
<br />Signature
<br />Date
<br />............. ..,........."...,, .K...."..
<br />
|