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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />d.'*** Steri! yCl@° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-024-5300 STANDARD MANIFEST oDt-10.06STO
<br />• �A Route #: 123 — 14 CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number ll II
<br />GILL MEDICAL CENTER
<br />f 1617 N CALXFCRNIA ST
<br />S7tCKTONI CA 96204- 6117
<br />CU%MMER NUMBER Alliqu—nal GENEnAmws REourm=oN 0
<br />2A. DESCRIP71ON OF WASTE 26. CONTAINER TYPE 2C. NO. OF I W. VOLUME
<br />UNS?011, Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6.2, Pall 1Ptzh5 — An esa9 m,•\. i=4^% fS 9 n.• F4•\ 1 r„ ¢e
<br />IN
<br />Designated Facility: cr,
<br />lSterics Inc. 4`-''
<br />4135 Wycl,
<br />Fresno,CA x3722 ti
<br />(866)783.7422
<br />7WOST72 .._:
<br />819. Alternate Facility:
<br />St dcyde, Inc.
<br />90 N. Foxboro orIm
<br />7 North Safi Lake. uT 84054
<br />7
<br />a4448 -JA -36
<br />TREATMENT FACILITY: I certify that: I have been authorized by the
<br />received the above indicated wastes In accordance with the requlrer
<br />Prirtt/rype Name Signature
<br />8C. Alternate FaclaW.
<br />3terIcycle, Inc.
<br />iSS1 shobn orwe
<br />Hollister, CA 85023
<br />(866)783-7422
<br />Tsfosr 83
<br />So. Alternate Faasity:
<br />Swrl%de, Inc.
<br />8940 N 7th StreetWy
<br />Kansas City, KS 6619 S
<br />(866)783.7422
<br />TSIOST-26
<br />icable state agency to accept untreated medical wastes and that I have
<br />outlined In that authorization.
<br />.Y containers, _ cu 2 - Norlh sial Lake, UT
<br />art\{eerevw{.
<br />6.2, PGII TB49 — 37 Gal Tub (ei4) (4.9 cu tt)
<br />Cu Ft
<br />CC
<br />Regulated Medica! Wade, R os ,
<br />6 2.
<br />p
<br />PGl3291 i
<br />TB14 — 44 Gal Tub (Bio) 0.9 cu tt}
<br />.r 9 Cu Ft.
<br />4
<br />U, PGI1 Regulaaed rtlsdisai waste, no.s, Tds21— (Br0) /TP15— (Path) /TY15— (Chemo) 20 Gal Tub (2.70UFT
<br />6.22, Pt'p
<br />Cu F4.
<br />NMI Regulated Medical Waste, It os„
<br />62, PGII WB31— (Bio) /tt1P31— (Path) /WC31— (Chemo) 31 Gal
<br />W
<br />Tub (4.140
<br />)
<br />Cu R
<br />UUN3 1f Regulated Medical Waste, n.o.s.,
<br />WM2— (Bio) IPW42— (Path) /C11042— Chaco Coal Tub 5.7curg
<br />Cu Ft
<br />UNMI Regulated MedW Waste, n.os.,
<br />62, Pali
<br />XRB — Bio stems cardboard Box 4.2 cu Et
<br />Cu F1
<br />UN6251 Regulated MedicalWaste, nos.,
<br />6.2, PGII
<br />Cu Ft
<br />UN320t Regulated Medical Waste, n os„ .
<br />6.2, PGII
<br />Cu Ft
<br />3. Generators Certification: •I hereby deolare that the contents of this consignment are fully and a urateiy TOTALS ®
<br />v Co Ft
<br />d above by the proper shipping name, and are classified, packaged, marked and labelled/pl rded, and
<br />respects In proper on lon for transport scorn fng to applicable Internabonal and nation a m en regulations"
<br />Pr edrryped Namema S e
<br />PORTER I AODRESS:
<br />hone 3
<br />783- 422
<br />Stericycle, Inc ° This is a Through Shipme
<br />�86f�j
<br />Applicable rmt umbers
<br />4136 N. Swift Ave
<br />Fresno,CA 93722
<br />8auler Reg# 3400
<br />a z
<br />TRANSPORTER_=4jTIFICATIO mipt of medma waste as descdb above
<br />�. v
<br />Prin"As Name Srg lure
<br />Date
<br />a
<br />5. INTERMEDIATE RMOLER 2JITRANSPOFITER 2 ADDRESS: Phone g•
<br />Applicable Permit Numbers.
<br />0
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PnnVrype Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS, Phone 0,
<br />a
<br />Applicable Permit Numbers*
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printltype Name Signature Date
<br />IN
<br />Designated Facility: cr,
<br />lSterics Inc. 4`-''
<br />4135 Wycl,
<br />Fresno,CA x3722 ti
<br />(866)783.7422
<br />7WOST72 .._:
<br />819. Alternate Facility:
<br />St dcyde, Inc.
<br />90 N. Foxboro orIm
<br />7 North Safi Lake. uT 84054
<br />7
<br />a4448 -JA -36
<br />TREATMENT FACILITY: I certify that: I have been authorized by the
<br />received the above indicated wastes In accordance with the requlrer
<br />Prirtt/rype Name Signature
<br />8C. Alternate FaclaW.
<br />3terIcycle, Inc.
<br />iSS1 shobn orwe
<br />Hollister, CA 85023
<br />(866)783-7422
<br />Tsfosr 83
<br />So. Alternate Faasity:
<br />Swrl%de, Inc.
<br />8940 N 7th StreetWy
<br />Kansas City, KS 6619 S
<br />(866)783.7422
<br />TSIOST-26
<br />icable state agency to accept untreated medical wastes and that I have
<br />outlined In that authorization.
<br />.Y containers, _ cu 2 - Norlh sial Lake, UT
<br />art\{eerevw{.
<br />
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