Laserfiche WebLink
40 ®®®SterlcycW SSE OF EMERGENCY CONTACT: CWEMTREC 1.800.424-9 <br />notectlnphopk. Rcdodnp RIX •Route #= 13.5 - 2 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001.10.06•STD <br />MDFRt CK075 <br />M ' i <br />1. Generator's Name, Address and Telephone Number <br />ATTN,John Menaugh <br />! [ <br />DOCTORS HOSPITAL OF MANTECA <br />l <br />1205 E NORTH ST <br />MA'NTECAr CA 95336- 4932 <br />CUSTOMeR NUMBER 6018849-002 GENERATOR'6 REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINERTYPE <br />2C. NO, OF <br />2D. VOLUME <br />Regulated Medical Waste, n.o.s., <br />62 <br />6,2, PGII <br />.. PG <br />5 - 4a Gal Tub (Bio) (5.3 ft) <br />TBU(Bau <br />CONTAINERS <br />Cu FL <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TB49 - 37 Gal Tub (Bi#) (4.9 cu 1;t) <br />Cu FL <br />CC <br />O <br />0 <br />623PGII Regulated Medical Waste, n.o.s., <br />TB14 - 44 Gal Tub(Hia) (5. au Tt) <br />�® <br />� Cu Ft. <br />Q <br />UN3291 Regulated Medical Waste, rwo.s., <br />x021- (Bxo)(rVjs - (Patio) f TYiS- (Chemo) 20 Gal Tub (2.7CUF'T) <br />6.2, PGII <br />S-• 2= Cu Ft. <br />Ili <br />W <br />UN3291 Regulated Medical Waste, n.o.s., <br />fi.2, P1311. <br />WB31- (Sia) /WiP31- (Path) / C31- (Chemo) 31 Gal Tub (4.14CUFT <br />Cu Ft. <br />O <br />6.2 32911 Regulated Medlca6Waste, n•o,s., <br />tit8Q3- (Bio) /pwd2- (Pati'} f Q3- (Chemo} Gal Tub (S. 70UPT) <br />cu Ft <br />UN3291 <br />23PGI� Regulated Medical Waste, n.o.s., <br />KRB - Biosystems Cardboard Box (4.2 au 1 t) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6,2, PGII <br />Cu Ft <br />3. Generator's Certification -.4 hereby declare that the contents of this consignment are fully and accurately- T®TALS ® <br />4t • Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placardad and <br />are In all respects In proper condition for transport according to applicable international and national gover ental regulations" <br />`Printod/typed <br />Name dY1'1� Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone #: (866) 783-7422 <br />Stericycler Inc. This is a Thro h Shipment <br />Applicable Permit Numbers - <br />4135 A. Swift Ave <br />Hauler Reg# 3404 <br />Fxeano,CA 93722 <br />ra <br />a <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printtiype Name lh tUL- C-A-31111TRA -a Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone # <br />AppBcable Permit Numbers: <br />� y <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recefpt of medical waste as described above, <br />Print/lypo Name Signature <br />Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />�u <br />Applicable Permit Numbers: <br />021 <br />2 1 <br />z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- <br />prindType Name Signature - - <br />Date -- - <br />7. DISCREPANCY INDICATION <br />Designated Facility: 8B. Aitomate Facility: ®80. Altemate Facility: <br />❑ 8D.Altemate Facility: <br />Stericycle, Inc. Ste a e. Inc. Skaricycle. Inc. <br />W <br />u- <br />4135 Swift.�4ve 80 M. FalxboYo Drive 1551 Shelton ©rive <br />Fresnla,A 93722 Norah Salt UT 84054 <br />Lake, Hollister, CA 95023 <br />•(866)783.74004XfiNE (866)783-7422 (956)783-7422 <br />TSIOST22 3A -44B- JWSS- TMST -83 <br />91 HOSC <br />14 <br />TREATMENT FACILITY: I car I y t at I have been authorized by the applicable state agency tciaccept e e a t (h ve <br />M <br />received the above in =4es In accordance with the requirement outlined In that authorization. <br />Printrrypo Name Signature <br />raaR — <br />GI <br />Tram effed conte hors, tai it ter <br />Zi <br />JACQUE WILSON <br />M ' i <br />