|
!!� MEDICAL WASTE TRACKING FORM NUMBER
<br />p®®p Stei�"icycle° I se OF EMERGENCY CONTACT: CHEMTREC 1-800-424.90 STANDARD MANIFEST 001-10.06•STD
<br />®® P,oieicftPeople, Redudn9ME' Route 0 132 — 1 CUSTOMER NO. 21132 MDFROOJSWM
<br />I
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:John Menaugh jj
<br />ji it
<br />DOCTORS HOSPITAL Cr MAITMCiL
<br />1205 E WORTH ST
<br />MAwrECA. CR 95:3:36- 4(1:32
<br />(209) 822-3111
<br />10/23/2017
<br />CusTOMERNUMBER 6018849-002 GENERATOR'$Rmir.TRATiom
<br />2A. DESCRIPTION OFWASTE
<br />28. CONTAINERTYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGIf
<br />TBtli5 -' 40 Gal Teti (81e?} (S.3 cu ft}
<br />CONTAINERS
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />6.2, PGI)'
<br />TB49 — 37 'Citi Tutt (Bi*) (4.9 Cu %t) '
<br />Cu Ft
<br />®
<br />1 Regulated Medical Waste, n.o.s.,
<br />T814 — 44 Gal Tub(Bi*) (5, 9 CU %t)CP
<br />Ft
<br />6UN
<br />Cu
<br />QUN3291
<br />Regulated Medical Waste, n.o.s.,
<br />TB21— (1320)/TP1S— (Path)/TX25— (Chemo)20 Gal Tub (2.7CUFT)
<br />6.2, PGII
<br />Cu Ft
<br />W
<br />UW291 Regulated Medical Waste, n.o.s.,
<br />titB31— (Blo) /WF31— (Fath) / C31— (Cliemo) 31 Gal Tttb (4,14CUPT}
<br />2
<br />6.2, PGI
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />62.PGIf
<br />A1843—(Hie)jPia143—(Path)/C 43—(ChemU) tial Tub(5.?.tt T)
<br />Cu Ft
<br />I! ,Regulated Medical Waste, n.o s
<br />6.2 ,
<br />, PG
<br />6.2, PG
<br />K 3 — Bitems Cardboard Box (4.2 cu ft)
<br />Biosystems
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGIl
<br />Cu Ft
<br />6 23291. Regulated Medical Waste, n.o.s.,
<br />, PGII
<br />Cu Ft
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTAL ®
<br />Cu Ft
<br />described above by the prop i Ing name, and are classified, packaged, marked and labelled/piacarded, and
<br />are In ail respects in proper nditlo for tra spo ac ording to applicable international and national ntal gulag
<br />I 4,
<br />Printedlfyped Name Si natu
<br />Date
<br />w
<br />4. TRANSPORTER 1 ADDRE S:
<br />Stericyc Inc.T 9 23 a T oitgh Skt�plaeltrt
<br />Phone #. (8616) 7 3-422
<br />Applicable Permit Numbers
<br />Q a
<br />,.e,
<br />47.36 W. Swift: Ave
<br />Hauler Reg#/ 3400
<br />N
<br />Fresno,CA 93722
<br />a ¢
<br />TRANSPORTS CE F TION: Receipt of medical waste as described above.
<br />it
<br />Printlrype Name Signature
<br />Date
<br />5. INTERMEDIATE H DLER 2 /T ANSPORTER 2 ADDRESS:
<br />Phone #
<br />IApplicable
<br />Permit Numbers*
<br />o�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />e;
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone #.
<br />SApplicable
<br />Permit Numbers,
<br />02
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />z
<br />Print/iSrpe Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Dosignated Facility: 8B. Alternate Feculty: 8C. Altemate Facility:
<br />8D Alternate Facllity:
<br />ftdCDA5AWB OFMZ Skedt ycle. Inc, Skerlcycle, inc.
<br />4135 . SWIt AVO 90 N. Foxboro Douai 1661 Shobn Drive
<br />FnBsno.CA 83722 North Salt Lake, UT M64 Hollister. CA 95023
<br />I—
<br />(866 7 (866)783-7x122 (866)783-7422
<br />2���
<br />Z
<br />TS! 2 3A-40%%36 TWOST83
<br />TREATMENT FAGiLI i certify that'l have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br />!—
<br />received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />PrinMpe Name I Signature .
<br />Date
<br />t
<br />ratisleirrea 1L comallne $ Gil ff fo—
<br />a
<br />
|