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p MEDICAL WASTE TRACKING FORM NUMBER
<br />®i ®O 5'�tt,.itr7Cycle! VASE OF EMERGENCY CONTACT: CHEMTREC 1800-024 STANDARD MANIFEST ooi-10.06 STD
<br />pmiectingpeopM k*dn9altk: Route 0: 135 - 2 CUSTOMER NO. 21132 MI)FR(jNTH'E
<br />1. Generator's Name, Address and Telephone Number
<br />ATTU-.John Menaugh
<br />DOCTORS HOSPITAL OF MANTECA
<br />1205 E 'NORTEi ST
<br />MAN7.' cn, CIS 95336— 4932
<br />(209) 823-311.1 10/26/2017
<br />CusTOMERNumarm 6018849-002 GENERATOR'sREctsTRAnoN#
<br />2A. DESCRIPTION OFWASTE 2B. CONTAINERTYPE
<br />UN3291 Regulated Medical Waste, mas.,
<br />6.2, PGII T$t3i5 - 40
<br />tai Tub ( u) (5. 3 CU ft)
<br />UN3291 Regulated Medical Waste, n.o,s ,
<br />6.2, 1`611T049 _ 37 Gal Tub (Bio) (4.9 cu tt)
<br />pC UNS291 Regulated Medical Waste, n,o.s„
<br />6.2, pall T014 - 44 Gal Tub (EW (5-9 Wax Tt)
<br />®
<br />4 UN3291 Regulated Medical Waste, n,os, T821-(BIo t- (path TY' (Ciietno)20 Gal Tub(2.?CUFT)
<br />OR 6.2. PGII
<br />W UN3291 Regulated Medical Waste, n o.s., .,
<br />ZZ 6.2, PGII WB31- (Bio) /wp3.1-- (Fatti) /WC3i- (tChelna) 31 Gal Tttb (4.14CUFT,
<br />66 2, Poll Regulated Medical Waste, n.O.s., X1843- (Bio) IPW63- (Fat3a) /CW43- (Chemo) Gal Tub (5.7 TUFT)
<br />UN3291, Regulated Medical Waste, nx.s ,
<br />62, PGII KRB - Biosystems Cardboard Bost (4.2 cu ft)
<br />UN3291, Regulated Medical Waste, n.o.s ,
<br />6 2, PGii
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />6.2. PGII
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately7iffr.
<br />descritled above by the proper ng name, and are c ssified, packaged, marked and labelled/placard an01are in all respects In proper dation for transpor acro in appli ble international and national g ent
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<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />0
<br />Cu Ft.
<br />Hauler Reg# 3400
<br />Cu Ft.
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<br />iPrintecirfyped NameSignat re
<br />4. TRANSPORTER 1 ADDRE
<br />Steric'yclea, Ina. This is a Through shipment
<br />IL v Date
<br />Phone t (1366) 7 3 7472
<br />Applicable Permit Numbers:
<br />0
<br />4135 W. 5sfit't: Ave
<br />Hauler Reg# 3400
<br />Fres'110'r_A 93722
<br />a ¢
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Printflype Name ����'' :.f ►J�L �� Signature
<br />Date 'd h-drZ4.
<br />S. INTERMEDIATE Hfit NDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />a
<br />'
<br />Applicable Permit Numbers -
<br />umbers•INTERMEDIATE
<br />IN I ERIVIEDIATEHANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />ca �,
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS,
<br />Phone 4 -
<br />Applicable Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-
<br />PrinVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. D4aignated Facility Be. Altemate Facility: ❑ 8C. Allemate Facility:
<br />81).Altemate Facility:
<br />3
<br />Ster€cy �;iw oiRTIZ rlc cle, Inc. SierIcyc€e, Inc.,
<br />41113 fI AVe 90 N. FwftrD DrW 1661 Shelton OtNe
<br />Fresno,CA93722
<br />X
<br />North Salt Lake. UT 54 Holl€stcr, CA 95023
<br />(Sasp'Tm 6 2017 (866,)783-7422 (861)7,33-7422
<br />T' 5
<br />--!I aaraas? AeQ y+`lF�+�S g
<br />TS/OST22 3A-418- 3 J;7'10 f 7t
<br />11ZLu
<br />TREATMENT FACILITY: ;"certify that I have been authorized by the applicable state agency to ac t ea
<br />indicated
<br />I ra i s at have
<br />,
<br />t--
<br />received the above wastes In accordance with the requirement outlined In that authorization.
<br />Print/Type Name Signature
<br />a
<br />Transferred containers, cu ft to
<br />V1Lu0i':i
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