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MEDICAL. WASTE TRACKING FORM NUMBER
<br />a® ®O ( E OF EMERGENCY CONTACT: CHEMTREC 1-800424-930 STANDARD MANIFEST 001 -10.06 -STD
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<br />° P,oledtpgPeople,Wudagalsk: Ratite #: 132 -° 2 CUSTOMER NO. 21132 MDFROO JXPA
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:Jahn Menaugh (j ii jj
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<br />DOCTORS B052ITAL OF MAZMCA
<br />1205 E WORTR ST
<br />MANTECA, CA 95336- 4932
<br />(209) 823-3111
<br />31/27/2017
<br />6018849--002
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,os.,
<br />`PBOS — 40 Gal Tub (Rio) (5.3 au ft)
<br />CONTAINERS
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<br />UN3291 Regulated Medical Waste, n.o.s.,
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<br />wj363— (Eio) Fwd2— (Path)CW@3— (Chemo) Gal Tub (5.7CIIFT)
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<br />3. Generator's Certification: °I hereby declare that the contents of this consignment are fully and accuratel TALE ®
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<br />described above by the prop hipping name, and are classified, packaged, marked and laballedJpia ed, a
<br />are in all respects in props on !tion for tra according o oppllcabie Internatlonal and national m an i regule
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<br />Printedfryped Name Signature
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<br />4. TRANSPORTER 1 D��g This is a Through Sizi laetrtt
<br />��e ycle, Inc.9 A
<br />Phone #
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<br />4135 W. Swift Ave
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<br />Applicable Reg#e 3400
<br />Fresnv,CA 93722
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<br />TRANSPORTS CERTIFICATION: Receipt of medical waste as described above.
<br />Print/type Name ` Signature
<br />Date ` 9
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers•
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printnype Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers.
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
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<br />Print/lype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />BA. Designated Facility: 88. Alternate Facility: ® 8C. Alternate Facility:
<br />Sterlcycle, Inc. Sterlcycle, Inc. Sterlcycle, Inc.
<br />8D. Altemate Facility:
<br />4135 W. SW2 AV* 80 N. Foxboro Drive 1651 Shelton OrNe
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<br />Fresno MPE OF North Salt Lake, UT 84054 Hollister. CA 95023
<br />(886)783-7422
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<br />(866)783-7422 (666)783-7422
<br />NQV 3 0 2017
<br />"NOV Z�17 3A -X148 -JA -36 T5i0�a"T 83
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<br />TREATMENT FACtt �'}fy that I have been authorized by the applicable state agency to accept untreated me nd that I have
<br />received the above indieatetKastes In accordance with the requirement outiined in that authorization.
<br />Print/lype Name Signature L1 E
<br />Date
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