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<br />° rrofating people, IItdy¢ngRisk'
<br />MEDiCALWASTtETRACKING FORMNUMBER
<br />OF EMERGENCY CONTACT: CHEMTREC't-800-424-0 STANDARD MANIFEST 001-10.06•STD
<br />CUSTOMER NO. 21132 vurn nnnirl tiR
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:John Menaugh
<br />DOCTORS HOSPITAL OF MANTECA
<br />12 U b E WORTH ST,
<br />MAIn=Ar CA 953:3-- 40:52
<br />pu4) 823-3111
<br />3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately I TOTALS 111 -
<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 Mlatfons:'
<br />12/21/2017
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS jI
<br />MIM
<br />(Printedf ed Name - .2 jIZ .kW jt�f j r C. -,l _f,'::. -- Signature DatefLige" u 7t
<br />CC 4.TRANSPORTt:R 1 ADDRESS:.� Phone#:(865) 783-7422
<br />Stericycle, Inc. This is a Through S pment Applicable Permit Numbers:
<br />0 4135 R. Swift Ave Hauler Reg# 3400
<br />a
<br />i Fresno, CA 93722
<br />o°G, odC TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print type Name NRAL %4`T! 4l/�� Signature Date I-?, / ly!
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print%pa Name Signature ' Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />I§ Applicable Permit Numbers:
<br />H INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print%pe Name Signature Date
<br />6160
<br />14
<br />;w A. Doslgrialaij Facility; 8a. Alternate Facility: ® 8C. Alternate Facility. Ej 80. Alternate Facility:
<br />U Stericycle, Inc. Sbacycle, Inc. Stedcycle, Ina.
<br />4188 W. SWiftA\h3 90 N. Fo oro, Drive 1551 Shelton Drive
<br />Fresno. North Sait Lake, Ur 84054 Hollister. CA 95023
<br />(866)783-7 2 (886)783-7422 (866)783-7422
<br />11SIOST22o i 17
<br />3A -"8 -JA -36 TS/OST 88
<br />TREATMENT FACILITY: !certify that I have been authorized by the applicable state agency to accept untreated medlcah'�st� A �� I have
<br />receiver! the above "W stes in accordance With the requirement outlined in that authorization. �tJJ�zttrr Qt LI i
<br />Print/rypeName Signature .11? daQI )F \AJ►i Si(Z f
<br />'Transferred containers, ou ft to
<br />�l
<br />CUSTOMER NUMBER 6018849--002 ,GENERATowsREGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2®• CONTAiNERTYPE
<br />91, Regulated Medical Waste, n.o.s.,
<br />6.2, P
<br />6A PGII
<br />TH05 _ 40 Gal Tub (Bio) (5.3 cu ft)
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />TA49 _ Gal Tub (Hie) (4:-9 CU TV
<br />CC
<br />6 2, Poll Regulated Medical Waste, n.e,s„
<br />TB14 _ 44 Gal Tub (Hina (5, 9 v'u 2t:)
<br />6 23FG1, Regulated Medical Waste, n.o.s.,
<br />Ts21-- (sxo)�- (Paeh) l 5- (Chemo) til Gal Tub (2.?Ctj T)
<br />!
<br />W
<br />UN3291 Regulated Medical Waste, n.c.s ,
<br />6.2,1`613
<br />W831—(Bio)/WP3.t—(Path)/WC31—(Chemo)31 Gal Tub(4.14CUFT)
<br />tZ
<br />6 2, FGit 329Regulated Madlcal Waste, n.o.s ,
<br />Wed2— (Bio) /md 3— (Path) /cw43-- (chemo) Gal Tub (5.7CUPT)
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII I
<br />KRR — ni-osystems Cardboard Box (4.2 au f1±)
<br />3. Generator's Certification: "1 hereby declare that the contents of this consignment are fully and accurately I TOTALS 111 -
<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 Mlatfons:'
<br />12/21/2017
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS jI
<br />MIM
<br />(Printedf ed Name - .2 jIZ .kW jt�f j r C. -,l _f,'::. -- Signature DatefLige" u 7t
<br />CC 4.TRANSPORTt:R 1 ADDRESS:.� Phone#:(865) 783-7422
<br />Stericycle, Inc. This is a Through S pment Applicable Permit Numbers:
<br />0 4135 R. Swift Ave Hauler Reg# 3400
<br />a
<br />i Fresno, CA 93722
<br />o°G, odC TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />~ Print type Name NRAL %4`T! 4l/�� Signature Date I-?, / ly!
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print%pa Name Signature ' Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />I§ Applicable Permit Numbers:
<br />H INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print%pe Name Signature Date
<br />6160
<br />14
<br />;w A. Doslgrialaij Facility; 8a. Alternate Facility: ® 8C. Alternate Facility. Ej 80. Alternate Facility:
<br />U Stericycle, Inc. Sbacycle, Inc. Stedcycle, Ina.
<br />4188 W. SWiftA\h3 90 N. Fo oro, Drive 1551 Shelton Drive
<br />Fresno. North Sait Lake, Ur 84054 Hollister. CA 95023
<br />(866)783-7 2 (886)783-7422 (866)783-7422
<br />11SIOST22o i 17
<br />3A -"8 -JA -36 TS/OST 88
<br />TREATMENT FACILITY: !certify that I have been authorized by the applicable state agency to accept untreated medlcah'�st� A �� I have
<br />receiver! the above "W stes in accordance With the requirement outlined in that authorization. �tJJ�zttrr Qt LI i
<br />Print/rypeName Signature .11? daQI )F \AJ►i Si(Z f
<br />'Transferred containers, ou ft to
<br />�l
<br />
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