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T _ MEDICAL WASTE TRACKING FORM NUMBER <br />••® i STANDARD MANIFEST 001 -10 -MSM <br />p ;O <br />Steric j/C1e• IN CASE OF EMERGENCY CONTACT: CHEMTREC t-800-A2AA300 <br />• rwftolivya Route #: 1.23 - 12 CUSTOMER NO. 21132 MDFR001iKKV <br />. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1.61.7 W CALIFORNIA ST <br />STOcKTON, CA 95204- 6117 <br />(209) 451-9031 <br />CUSTOMER NUMBER 6111852-001 GENERMR%REatsrnAnoN9 <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO. OF <br />UN3291 Regulated Medical Waste, n.o s, CONTAINERS <br />6.2, PGII T1i05 - h0 Gal Tub (sio) (5.3 Cu •ft) <br />UN3291 Regulated Medical Waste, n.o.s , Tp49 - 37 Gal Tub (Bio) (4.9 Cu tt) <br />6.2, PGII <br />UN329t Regulated Medltal Waste, n o s., <br />6.2, PGII T014 — 44 Gal Tub (Sio) (5.9 Cu it) <br />FFF <br />6N32911 Regulated Medical Waste, nos,, T921— (Bx0) /TFi5— (Path) /TXiS— (Chemo) 20 (gal Tub (2.7CUF ) <br />W UN8291 Regulated Medical Waste, n.o s., WB31— (Bio) /Wp3l— (path) /WC31— (Chemo) 31 Gal Tub (4.14C ) <br />Z 6.2, PGII <br />6 2, PGII Regulated Medical Waste, n.o s., WB43- (Bio) /PW43— (Path) /Cfd43— (Chemo) Coal Tub (5.7CUFT) <br />6 <br />UN3291 <br />gPG11 Regulated Medical Waste, n.a.s., KRB_ - Biosystems Cardboard Box (4.2 cu tt) <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />3. Gen tows Certification: I hereby declare that the contents of this consignment are fully and accu TOTALS <br />Xn <br />above by the proper shipping name, and are classified, packaged, marked and labelted/placa ed. and <br />allaspects in props rout ition ®for/t�ransport according to applicable international and nations me regulat V <br />P ted/iSread Name \_K� S <br />a. SPORTER 1 ADDRESS: <br />Stericycle, Inc. <br />4135 V. Swift Ave <br />N Freisno,CA 93722 <br />00„ TRANSPORTER RTIFICA : Rec elpt of medical waste as <br />PdnVfte Name .[gnat <br />5. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: NllJ <br />III <br />115R1 INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Pdnt/Type Name Signature <br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />P INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdnllfype Name Signature <br />7. DiSGREPANCY INDICATION <br />Designated Facility: <br />Stericycle, Inc. SNE <br />X36 W. S%MftAV8 <br />Fresno(866)78CA 93 <br />3-7A2 R 0 8 <br />TMST22 <br />80. Alternate Facility. <br />Sterlcycle.Inc. <br />90 N. Foxboro Olive <br />North Soft Lake, Ur M54 <br />(866)783-7422 <br />3A-A48,W36 <br />6C. Mtemate Facility: <br />Stlerlcycle. Inc. <br />1551 Shelton Drive <br />Holllster, CA 95023 <br />(866)783-7422 <br />TWOST 83 <br />3/8/203.6 <br />VOLUME <br />Phone#: (866)783-^7422 <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date <br />Phone # <br />Applicable Permit Numbers <br />Date <br />Phone #. <br />Applicable Permit Numbers <br />Date <br />W. Alternate Factnty: <br />Stericycle, Inc. <br />3140 N 7th StmetbV <br />Kansas CItY, KS 66 116 <br />(866)783-7422 <br />TS10S'I =26 <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 />received the above Indicated wastes In accordance with the requirement outlined In that authorization. <br />Print/lype Name Signature Date <br />t:Ontalnem, CII R to : <br />Ft <br />