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• MEDICAL WASTE TRACKING FORM NUMBER
<br />®® Stericycte° OASE OF EMERGENCY CONTACT: CkEMTREC 11-800-424-0 STANDARD MANIFEST 001.10.06•STD
<br />• p,atenlnppaopN.RdudnpRise Route 0: 135 -- 8 CUSTOMER NO, 21132 MDFRIDUY9Z
<br />RI INAL P
<br />1. Generator's Name, Address and Telephone Number
<br />ATTNaJahn Menaugb
<br />DOCTORS HOSPITAL OF MANTECA
<br />1206 E NORiR ST
<br />MA'NTECA, CA 95336- 4932
<br />(209) 823-3111. 11/30/2417
<br />CusioMER NUMBER 6018849-002 GENENAToR's REGismnoN #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO. OF
<br />21D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o s,
<br />6.2, PGII
<br />TBO5 - 40 Gal Tub (Bina (5.3 cu ft)
<br />CONTAINERS
<br />Cu Ft
<br />82313131` Regulated MedlcalWaste, n.o.s.,
<br />TB49 _ 37 Gal. Tub {Bio} (4.9 Cu ft)
<br />Cu Ft
<br />(�
<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />TBl4 - 44 Gal Tub {Biu) (5.9 cu ft)
<br />OR
<br />6.2, PGI
<br />'53.1
<br />Cu Ft.
<br />Q
<br />6 2326 Regulated Medical Waste, n.o.s.,
<br />TB21- (BXO 1315- (path) /Tx15- (Chemo) Zit Gal Tuts (2.7�Ctit^ T)
<br />2- �"
<br />•
<br />Cu Ft.
<br />W
<br />Z
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, PGII
<br />WB31- (Bio) /WP31-- (Patb)/WC31- (Cheino) 31 Gal Tub(4.14�CEJFT
<br />Cu FL
<br />6.2. P811 Regulated Medical Waste, n.o,s.,
<br />WB43- (Bio) /PW43- (Path) / 43- (Cbemo) Gal Tub (5.7CuFT)
<br />Cu Ff.
<br />UN3291 Regulated Medical Waste, n.o.s,
<br />6.2, PGI)
<br />ICRB - Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, 1`611
<br />1
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n,o,s.,
<br />6.2, PGI
<br />Cu Ft
<br />3. Generator's Cortiticatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® $d
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and iabelled/placarded, and
<br />are In all respects In proper condition for transport a ording to applicable International and national governmental re tions"
<br />V®!
<br />(Printe"ped � e1i�
<br />Name At/ -Signature Date ✓
<br />cc
<br />4. TRANSPORTER I ADDRESS: Phone#. (866) 783-7422
<br />��utt
<br />Ster�,aWle, Inc. CK This is a Through ? L Applicable Permit Numbers:
<br />�c
<br />4135 A. Swift Ave Bauler Reg# 3400
<br />Freario, CA 83722
<br />a Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describ above.
<br />IV
<br />FE
<br />PrinMpe Name ei5" 7i1,j'a Signature Date bola
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone C
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintMype Name Signature Date
<br />i
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />W§
<br />Applicable Permit Numbers:
<br />ws� �
<br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PdnVType Name Signature Date
<br />7'. DISCREPANCY INDICATION
<br />day
<br />INNA.
<br />Doetgnated Facility: UbIL Alternate Facility: ® aC. Alternate Facility: Ej BD. Alternate Facility:
<br />Sterlcycle, Inc.Swricycle, Inc. Stericycle, Inc,
<br />a
<br />41W W, vWtAW 90 N. FOAO c DrW4 1551 Showorlaa
<br />t+-
<br />Fresno,CA 83722 North Sett Lat(e, UT 84054 HoMster, CA, 95023
<br />(886)789-7422 VA.La* . I2 (866)783-7422 (886)783-7422
<br />' IS10=2 BA -448 -JA -36 TWOST 83
<br />p#,�yt
<br />TREATMENT FACILIN0lrce%g firg� dt have been authorized by the applicable state agency to accept untreated medical wa a
<br />received the above indicated wastes in accordance with the requirement outlined In that authorization. \ d
<br />� R E.,., 11 iI
<br />Pdnnpe Name Signature
<br />Transferred containers, eu t3 to : nt- C' _! tl 7I117
<br />r
<br />JACQUE WILSON
<br />RI INAL P
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