Laserfiche WebLink
i• MEDICAL WASTE TRACKING FORM NUMBER", <br />O® ®O SterlCyCle' IN CASE OF EMERGENCY CONiAC% CHEMTREC 1-so0.424 9300 STANDARD MANIFEST 001.10.06 -STD <br />• <br />F101,101111; . a ate. Route #: 123 ^ 20 CUSTOMER NO. 21132 On <br />1. generator's Name, Address and Telephone Number HM <br />ATTN-. <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOCKTON, CA 95204- 6117 <br />ClUrrOMER NUMBER 971_ i t <br />2A. Di:SCRIPTION OF WASTE 213. <br />UN3291 Regulated Medical Waste, no.s., <br />6 2, Pari <br />UN3291 Regulated Medical Waste, no s., <br />6.2, Pati <br />p6N3291 Regulated Medical waste, n.os., <br />Q UN3291 Regulated Medial Waste, n o.s., <br />X 6.2, PGIJ <br />W UN3291 Regulated Medical waste, n os <br />U.1 <br />d <br />6.z, PG <br />UN3291 Regulated Medial Waste, n,os , <br />6.2, PGI <br />waste, n.0 e <br />waste, n.0 s <br />111111111111111101111111111111111111111111111111 <br />GENERAToFrs REeIaTRArm # <br />JNER TYPE 20. NO. OF <br />CONTAINERS <br />TB49 _ 37 (dal Tub (Bio) (4.9 Cu ft) <br />TB14 - 44 Gal. Tub (Bio) (5.9 cu tt) <br />TB21- (BIO) /TP15- (Path) /TX15- (Chemo) 20 Gal Tub (2. <br />3. Ge erator's Certification: "I hereby declare that the contents of this consignment are fully and accuratel TOTALS i <br />ove by the proper shipping name, and are classified, packaged, marked and labelled/placarded nd <br />ar in all ' - Ids In proper ca lion for transport aqcorolng to applicable International and national m n ulations" <br />P driliped Name I ur <br />. ANSPORTER 1 ADDRESS: <br />Lu Steriaycle, Inc. This is a Through shipment <br />0 4135 X. swift Ave <br />99L Fresno,CA 9372 <br />ME <br />z TRANSPORTEReEBTIFIQATIOW pt of medical waste as do= a <br />VOLUME <br />Phone A is Pdmmi&783-7422 <br />4 <br />Hauler Reg# 3400 <br />Date <br />`3 �l <br />E. INTERMEDIATE UNt LFFr2YTRANISPORTER 2 ADDRESS: Phone #• <br />'d <br />Applicable Permit Numbers <br />log <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnMps Name Signature Date <br />0 <br />�1 <br />C:, al s. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Mone tl: <br />1q Applicable Permit Numbers: <br />I INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />z <br />PrWIFype Name Signature Date i <br />a <br />H <br />DREPANCY INDICATION <br />Designated Facility iB. ARemata Facility: SC. Altemate Facility. <br />aD. Altemate Facility: <br />4135 W.eStInc. Stedcycie, Inc. Sterlcyale, Inc. <br />Stedcyde, Inc. l <br />PH�SO 90 N. Foxboro Dura 1551 5hetton owe <br />3140 N 7th Streettry <br />Fresno,CA 8 North Salt Lake, UT 84054 Hollister. CA 85023 <br />Kensas C9y K3 66115 <br />)5422 ,� (866)783-7422 (866)783-7422 <br />4 <br />(866)783-7422 <br />TS/OM23�ws . 3& TWOST 83 <br />�pR D <br />TWOST 26 <br />f MENT FACILITY: i )jdjif- thfi Nave been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />the indicate <br />ad above wastes in accordance with the requirement outlined in that authorization. <br />i <br />)e Name Signature Date <br />Transferred containers, eu ft to : North Sak lake, IIT <br />