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hotecdng people. Redudoo Risk. MEDICAL WASTE TRACKING FORM NUMBER OASE OF EMERGENCY CONTACT; CHEMTREC 1-800-424-01 STANDARD MANIFEST 001.10•06•STD Route #: 132 — ,1 CUSTOMER NO. 21132 MDFROOJY07 1. Generator's Name, Address and Telephone Number ATTI404hn Menauirib DOCTORS HOSPITAL. OF MA'NTECA 1205 E FORTH ST MANIECA, CA 95336- 4932 (209) 823-3111 12/4/2017 4. TRANSPORTER 1 ADW15tS: Phone#. (1366) 7133-7422 a Stericyc7.e}, Inc. T is a Through Shipment Applicable Permit Numbers - 4135 W. Swifl: Ave rs Hauler: Regi 34II0 a. E'reano, CA 93722 U) a°G Q TRANSPOI E E TIFICATION: Receipt of medical waste as described Print/Type Nam Signature Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone If: 1hApplicable Permit Numbers- R 0 INTERMEdfATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printrtype Name Signature Date :WN6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 11- WNW W Applicable Permit Numbers - 2 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Print/7ype Name Signature Date 7. DISCREPANCY INDICATION IN 8A. Designated Facility: N..4 CUSTOMER NUMBER 6018849--002 GENERATOR'S REGISTRATION# t__t BC. Alternate Facility: 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO. OF 2D. VOLUME 4186 W. SWftAve UN3291 Regulated Medica! Waste, n.o s ,CONTAINERS TB05 — 90 Gal Tub (Bit+) (5.3 cu iiG) 1551 Shetton Drive Fresno.CA 93722 North Salt lake. LIT 84054 8.2. PGIi (856)783-7422 MAN O Cu Ft. (866)783-7422 UN3291 Regulated Medical Waste, n.o,s., TH4.9 — 37 Gal Tub (Biu} (4.9 OU '✓ t) 6.2, PGIi 3A -448%x-36 Cu Ft. CC 6N3291i Regulated Medical Waste, n,o.s., TB14 — 44 Gal Tub (Bio) (5-9 .'u ft) ` cu Ft. !OR-UN3291 Regulated Medical Waste, n o,s., TB21— (BIO)/TP15— {Path} / 5— (Chemo)20 Gal Tub (2.7CUFT} jr 6.2, PGII ✓ Cu Ft Medical Waste, n.o.s,, WB31— (Bio) /WP31— (Page) /WC31— (Chetnls) 31 Gal. Tub (4.14CUFT 82. PGI Z Regulated II Cu Ft W (5 UN3291 Regulated Medical Waste, n.o s., 6.2, PGI) WB03— (Bial/Ptdl3— (Path} /CWR?3— (C]aemo} Gfil Tub (5.7CUF'T) Cu Ft, UN3291 1`6II Biosystems Cardboard Regulated Medical Waste, n.o.s., 6.22,,PGKRB — BitCrdbord Box (9.2 cu ft)Cu FL UN3291 Regulated Medical Waste, n.o.s., 6.2, PGII Cu Ft. N329G11� Regulated Medical Waste, n.o,s., „ 6 Cu Ft t 3. Generators Certification: "i hereby declare that the coolants of this consignment are full telt' TOT S ® L ''� Cu Ft. described above by the pr Ipping name, and are classified, packaged, marked and elled1placarddand of condi on fol trajisppq according to applicable international and natignal gove r, entat are In all fospects In pr • 4. TRANSPORTER 1 ADW15tS: Phone#. (1366) 7133-7422 a Stericyc7.e}, Inc. T is a Through Shipment Applicable Permit Numbers - 4135 W. Swifl: Ave rs Hauler: Regi 34II0 a. E'reano, CA 93722 U) a°G Q TRANSPOI E E TIFICATION: Receipt of medical waste as described Print/Type Nam Signature Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone If: 1hApplicable Permit Numbers- R 0 INTERMEdfATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Printrtype Name Signature Date :WN6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 11- WNW W Applicable Permit Numbers - 2 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Print/7ype Name Signature Date 7. DISCREPANCY INDICATION IN 8A. Designated Facility: N..4 Lj.EI3. Alternate Facility: t__t BC. Alternate Facility: Sterlcycie, Inc. S ftycle, Inc. Slrricycle, Inc. 4186 W. SWftAve SO N. Foxboro Drive 1551 Shetton Drive Fresno.CA 93722 North Salt lake. LIT 84054 Hollister. CA 95023 (856)783-7422 MAN O (886)783-7422 (866)783-7422 TSIIOST22 3A -448%x-36 TSIOST 83 U 8D. Alternate Facility: i TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical e rid thya a received the above Indlea rein accordance with the requirement outlined in that authorization. Pr(nt/7ype Name Signature ff JACCE d ILLSON II b