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MEDICAL WASTETRACKING FORM NUMBER <br />0S"tericyCle° 7y SE OF EMERGENCY CONTACT: CHEMTREC 1-800-4241 STANDARD MANIFEST 001-10-06-STDm ProleNnphopil.Redudn9RIS Route #: 132 — 1 CUSTOMER NO. 21132 MDFROOKOLN <br />K;K'' lIRF.1 <br />1. Generator's Name, Address and Telephone Number <br />ATTN.John Menaugh jj <br />j( Jj <br />DOCTORS HOSPITAL CE I4AMMCA <br />1205 E NORTH ST <br />MANTECA, CA 95336- 4932 <br />(209) 823-3111 <br />12/18/2017 <br />CUSTOMER NUMBER 60-18849-002 GENERATows REaisTRATION # <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PGI! <br />TBOS — 40 Gal Tub (Bio) (5.3 CU ft) <br />CONTAINERS <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.c.s., <br />6,2, PGI! <br />TB49 — 37 Gal � (Sio) (4.9 Cit 'Et) <br />Cu Ft. <br />®UN3291 <br />23PGIL Regulated Medical Waste, n.o.s., <br />TH14 — 44 Gal 'Pub Dio) (5®9 CU ft) <br />`� <br />� <br />Cu Ft. <br />QUN3PGII <br />Regulated Medical Waste, n.o.s., <br />T821— (83:o) /TFIS— (Fath) /TY15- (Chemo) 20 Gal Tub (2.7CUFT) <br />M <br />Cu Ft <br />lit <br />� <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGI <br />WE131— (Sao? /WP31— (Path) /WC31— (Chem*) 31 Gal Tub (4.14CUFT <br />Cu Ft. <br />6 2, Poll Regulated Medical Waste, n.a.s., <br />wBd3— (Bio) /pwd2— (Path) / d3— (Chemo) Gal Tub (5.7cUFT) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />— <br />KRB Biosystems Cardboard BOX (4.2 cu tt) <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medial Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />3. Generator's Certification, "I hereby declare that the contents of this consignment are fully and accurately TOTALS Do - <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />described <br />are In all respects In proper condition for transport cording to applicable International and nakonaf governmental r bons" <br />I IPrinted%pedName <br />J <br />t7 GR. Signature <br />Date��~` <br />cc <br />4. TRANSPORTER i ADDRESS:Phone <br />#: (8 66) 783-7422 <br />Stericycle, Inc. This is a Th.Coug Shim nt <br />Applicable Permit Numbers: <br />a o <br />4135 W. Swift Ave <br />Hauler Reg# 3400 <br />g n. <br />Eresno,GA 93722 <br />RE <br />TRANSPORTER ER FI ATION: Receipt of medical waste as described above. <br />GZ <br />N <br />L., r <br />Print%pe Name Signature <br />Date <br />,. <br />5. INTERMEDIATE HANDLER /TRANSPORTER 2 ADDRESS: <br />Phone M <br />N <br />Applicable Permit Numbers: <br />�+ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print/ ype Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />#: <br />PhoneIc <br />Q <br />Applicable Permit Numbers: <br />Q 3 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />N6 <br />Print%pe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />SA. Designated Facility: 8B. Alternate Facillty: ❑ 8C. Alternate Facility: <br />Sterlcycle, Inc. Sterlcycle. Stedcycle, Inc. <br />IF1 80. Alternate Facility: <br />Inc. <br />a <br />4136 W. SWR Ave 90 N. Foxboro Drive 1661 Shelton Drive <br />IL <br />Frasno.CA 937 E OrM E Nori3t Salt Lake. UT 840Whiter. CA 95023 <br />#866)783-7422 (866)783-7422 <br />Z(886)788-7422 <br />Lu <br />8s <br />Ti f8ff'12DEC <br />18 201 <br />TREATMENT FACILITY. I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />P <br />received the above 1ndlceQAAi&t&4n accordance with the requirement outlined in that authorization. <br />v <br />Prrnt/Typs Name Signature <br />Date <br />Transferred containers, cu A to <br />�a <br />K;K'' lIRF.1 <br />