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— — — - -- — — — - MEDICAL WASTE TRACKING FORM Nthw. k l <br />-000* tericycl1 e° SE OF EMERGENCY CONTACT:CHEMTREC 1-800-424* STANDARD MANIFEST 001 -10.08 -STD <br />• Protecting People ReducingRLk:Route #: 135 _ 8 CUSTOMER NO. 21 . MDFROOK22J - -- _--- <br />Transferred / coma • -7- at A to <br />JAN 0 4-2018 <br />JACQUE WILSON <br />1. Generator's Nome, Address and Telephone Number <br />ATTNaJohn Menaugh <br />DCCTOR5 B05121TAL OF MA1t=CA <br />1205 H NORTH ST <br />MAWTECA, CA 95336- 4932 <br />(209) 823-3111 12/28/2017 <br />CusTOMERNuMBER 601.8849--002 GENERATOR'sREGISTRATION# <br />2A. DESCRIPTION OP WASTE <br />23• CONTAINERTYPE <br />2C'NO. OF <br />2D. VOLUME <br />6 23 111311GRgulated Medical Waste, n.o s., <br />TB05 - 40 Gal Tub (BIG) (5.3 Cu 'Et) <br />CONTAINERS <br />Cu Ft. <br />UN3291 <br />23PG1� Regulated Medical Waste, n.o,s., <br />TS49 „ 37 Gal Tub (Rio) (4.9 Cu tt) <br />Cu Ft. <br />CC <br />® <br />UN3291 Regulated Medical Waste, n,o,s„ <br />6,2, PGI{ <br />TSl4 - 44 Gal Tub (Bio) (5.9 au ft) <br />57Z <br />p . S Cu Ft. <br />UN3291 Regulated Medical Waste, n.os., <br />TH21- (210) - (Path) /T1i15- (Chemo) 20 Gal Tub (2.7CUFT <br />® <br />6.2, PGII <br />G Cu Ft <br />W <br />W <br />UN3291, Regulated Medica) Waste, n.o.s., <br />6.2, PGII <br />WB31- (Bio) /VV31- (Path) / 31- (Chemo) 31 Gal Tub (4.14CUF) <br />Cu Ft, <br />UN3291 <br />6 2GReguiated Medical waste, n.o,s., <br />, <br />WB03- (B i -o) /PW43- (Path) / 03-- (Chemo) Gal Tub (S. 7CUF'T) <br />' <br />Cu Ft <br />UN3291.Regulated Medical Waste, n.o,s., <br />6.2, PGII <br />PMB - Siosystemis Cardboard Box (4.2 cu ft) <br />Cu Ft. <br />UN3291 Ragulated Medical Waste, n,o.s,, <br />U. PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s„ <br />6,2, PGII <br />Cu Ft <br />TALS 0" 32 Z Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurateAan <br />described above by the proper shipping name, and are classified, packaged, marked and labeged(placardeare In <br />fn dillon fe ternationai <br />all respects proper riling toappifc end nabonai governns" �� <br />MPrintedRyped <br />hen, <br />Name Signature Date <br />a <br />4.TRANSPORTER 1 ADDRESS: / Phone #: (86�&) 783-7422 <br />Stericycle, Inc. This is a T ough Shipment Applicable Permit Numbers. <br />4135 W. Swift: Ave Hauler Reg# 3490 <br />y <br />Freano,CA 93722 <br />per„ <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />0QC <br />~ <br />iZ f 2-'K / )9" <br />PrinMpeNameSignatur® Date <br />., <br />8. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS- Phone #: <br />' <br />Applicable Permit Numbers: <br />a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. "• <br />PrinMpe Name Signature Date <br />S. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #: <br />� I <br />Applicable Permit Numbers: <br />oilN <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />-- <br />Print/lype Name Signature Date <br />7. DISCREPANCY INDICATION <br />e <br />A. Designated Facility: Be. Alternato Facility: 0 8C. Alternate Facility: <br />F180. Altemate Facility- <br />Slfieiicyycle, inc. Steri le, Inc. Sberleyde, Inc. <br />4136 W. <br />w so N.oxbm Drive 1551 Shubert Drive <br />Fresno 22 North Salt Lake. UT 54 Hollister, CA 95023 <br />%)7� (866)783-7422 (866)783-7422 <br />3Ar448ti1Ar86 TStOST 83 <br />' <br />CIO <br />TREATMENT ��� tTY: I�t ffy that I have been authorized by th ppiltcab to agency to accept untreated medical <br />received th)" ed t(6�tvastes in accordance with the reent outlined t authorization. <br />wastes and at I have <br />Print1wo Name Slgnature <br />!t <br />1 4 D <br />Transferred / coma • -7- at A to <br />JAN 0 4-2018 <br />JACQUE WILSON <br />