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MEDICAL WASTE TRACKING FORM NUMBER
<br />0;•®p terlcyl: e° ASE OF EMERGENCY CONTACT: CHEMTREC 1-8011.424.0 STANDARD MANIFEST 001 -10.06 -STD
<br />kolecting People. Reducing Risk: Route #: 135 6 CUSTOMER NO. 21132 MDFRQOJZ8S
<br />i
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:John Menaugh
<br />DOCTORS HOSPITAL OF M V=CA
<br />1205 E 'NORM ST
<br />MANTECA, CA •95336— 4932
<br />(2091) 823-3111 12/7/2017
<br />CusmilveR NumaEn . 6018949-002 GaNERAroRT R1501MA710N #
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2C NO.
<br />NO.OF 2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s., 'PLIAS - An Gal Tub fBio} (5.3 Ou it) • CO
<br />UN3291 RoDulated Medical Waste, n.o.s.,
<br />6.2. PGII,
<br />3. Generator's Certification: uI hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects In proper condition for transport according to applicable international and national governmental regli"ns"
<br />c
<br />%#—%. r+
<br />a 4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />4135 V. Swift Ave
<br />gm Frers:Ino,CA 93722
<br />a Q TRANSPORTER CERTIFICATION: Receipt of medical waste as
<br />Printflype Name wv L;A'O Slgnati
<br />This is a Through
<br />1 Date /G
<br />hone #• (8166) 783-7422
<br />Applicable Permit Numbers.
<br />Hauler Reg# 3400
<br />Date
<br />8. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />N
<br />E� Appikable Permit Numbers:
<br />y INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpo Name Signature Data
<br />M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printlfype Name Signature
<br />7. DISCREPANCY INDICATION
<br />Applicable Permit Numbers:
<br />Date
<br />Cu
<br />6.2, PGI1
<br />.8ta. Alternato Facility:
<br />❑ 8C. Alternate Facility. [] 8D. Attemate Facility:
<br />UN3291 Regulated Medical Waste,n.o.s,
<br />6.2,'Pall,
<br />T849 - 37 Gal Tub, (Ri0, (4.9 Cu ft)
<br />Stsricyclee Inc.
<br />Ir
<br />UN32911i,Regulated Medical Waste, n.o.s.,
<br />t�tl TU B:1. } (5. ou It)
<br />014 - 44 Sa
<br />•
<br />0..
<br />Fresno,C.,ANorth
<br />E Oil U
<br />Sal Laka, UT
<br />Hollister, CA 9.,023
<br />0
<br />6U2 291 Regulated Medical Waste, n.a.s.,
<br />xB21- (uT T1P1S- a1:h) / 1S- (c)irmo)20 981 Tub (2.7CUFT)
<br />(866)783.7422
<br />W
<br />Z
<br />U -Regulated Medical Waste, n.o.s.,
<br />Pil
<br />6.22,, PGIi;
<br />WB31- (Bio) /WP33.- (Path) /NC31- (Chemo) 31 Gal Tub (A.14CUF'T
<br />T3143T 83 -
<br />8 2, PGIi Regulated Medlcal Waste, n.os.,
<br />wH42- (Bio) /Pw43- (Path) J 3- (Chemo) Gal Tub (S.7CUPT)
<br />UN3291
<br />23PGti Regulated Medical Waste, n es.,
<br />X" - t#iosystem:s Cardboard Box (4.2 au ft)
<br />F-
<br />UN3291 RoDulated Medical Waste, n.o.s.,
<br />6.2. PGII,
<br />3. Generator's Certification: uI hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects In proper condition for transport according to applicable international and national governmental regli"ns"
<br />c
<br />%#—%. r+
<br />a 4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />4135 V. Swift Ave
<br />gm Frers:Ino,CA 93722
<br />a Q TRANSPORTER CERTIFICATION: Receipt of medical waste as
<br />Printflype Name wv L;A'O Slgnati
<br />This is a Through
<br />1 Date /G
<br />hone #• (8166) 783-7422
<br />Applicable Permit Numbers.
<br />Hauler Reg# 3400
<br />Date
<br />8. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />N
<br />E� Appikable Permit Numbers:
<br />y INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpo Name Signature Data
<br />M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printlfype Name Signature
<br />7. DISCREPANCY INDICATION
<br />Applicable Permit Numbers:
<br />Date
<br />Cu
<br />Al
<br />JACQUE WILSON
<br />Doetgnatod Facility:
<br />.8ta. Alternato Facility:
<br />❑ 8C. Alternate Facility. [] 8D. Attemate Facility:
<br />Sbsrlcycle, Inc.
<br />Sbaricyclee Inc.
<br />Stsricyclee Inc.
<br />0*4135 W. &AAV4
<br />r
<br />90 N. Foxboro Ofiv>tf
<br />1651 Shobn Dove
<br />0..
<br />Fresno,C.,ANorth
<br />E Oil U
<br />Sal Laka, UT
<br />Hollister, CA 9.,023
<br />t—
<br />(gag)- t�3-i4
<br />(SM783.7422
<br />(866)783.7422
<br />w
<br />1'31bST22$-,tA-
<br />' .1 y. ,
<br />T3143T 83 -
<br />DEC 07 2017
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable
<br />the Ind'
<br />state agency to accept untre e e I t
<br />that
<br />F-
<br />received above s In
<br />accordance, with the.regigement
<br />outirned in authonzatfon. a/
<br />Printltypal Name
<br />•
<br />Signature
<br />Date
<br />..
<br />'4'- Tmnsfeffed
<br />- I ' cofltane .
<br />eu ft to
<br />Al
<br />JACQUE WILSON
<br />
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