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stericycle- <br />:oktenp Pwgre. R.auda4 ebk' <br />v <br />MEDICAL WASTE TRACKING FORM NUMBI <br />jj CgqSE Og EM ENCY CQ�TACT: CHEN TREC 1-8044249300 STANDARD MANIFF.BT Wi-1008 STD <br />dUCR #: -^ J.3 CUSTOMER N0.21132 MDFROOF <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOCKTON, CA 95284— 6117 <br />(209) 451-9031 <br />CUMMER NUMBER 6111852-001 GeNeRarows Rscissnanon # <br />t 2A. DESCRIPTION OVWASTE 2g• CONTAINERTYPE <br />UN32P9r1 II Regulated Medical Waste,n.os., TBQ5 - 40 real Tub (Bio) (5.3 Cu ft) <br />6.UUN23� 01 Regulated Medical Wage, n.os , TB4 9 — 37 Gal Tub (Bio) (4.9 cu TV <br />it UN3291 Regulated Medical Waste, n.os, TB14 — 44 Gal Tub (Bio) (5-9 Cu ft) <br />® 6.2, PH <br />Q UN3291 Regulated Medial Waste, n.as., a _ o <br />6.2, PGIf <br />iW UN3291 Regulated M cal Waste, n os , WB31—(8 o)WP31— (Fath)IdC31—(Chemo) 31 Gal Tub (4.14CUFT <br />6.2, PGIE <br />W UN3291I Regulated Med i Waste, nos.. wB43— (bio) /P>tt43— (Pada) /CW&2— (Chemo) Coal Tub (S.7CUPT) <br />UN3291 Regulated Medical Waste, n os., KAB� — Biosystems Cardboard Box (4.2 Cu ft) <br />6,2, 13611 <br />ON3291 Regulated Medical Waste, n.o s, <br />6.2, PG1I <br />UN3291 Regulated Madw Waste, n.o s., <br />6.2, PGH <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS % <br />doom0ed above by the proper shipping name, and are classified, packaged, marked and label) ed, and <br />e IPA respects In proper condition for transport according to appicabie International and natiTi%govilfrimental regulations" <br />3/22/2016 <br />2C. NO.OF 2D. VOLUME <br />CONTAINERS <br />4, TRANSPORTER 1 D E N---ePhone#: (ttbb) f UJ— f 9LL <br />6 �RTHEycle, Inc. This is a Through Shipment <br />4135 W. Swift Ave AppliPerini Numbers <br />Hauler Reg# 3400 <br />rcesno,CA 93722 <br />a TRANSPORTE ERTIFICATION: pqr of medical waste as descnb <br />Prfnttiype Name Signature Date <br />` 8. INTERMEDIAT NDLER 2 / TRANSPORTER 2 ADDRESS: Phone 2 <br />p1 Applicable Permit Numbers' <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION' Remipt of medical waste as described above <br />Pnntnype Name _ Signature Date <br />M 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS, Phone #. <br />Applicable Permit Numbers• <br />xa INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a <br />Ic — Printriype Name Signature Date <br />7. DISCREPANCY INDICATION <br />Designated Facility: 01 <br />Stericycle, Inc. pctir'� <br />35W. St+Ytlgj?t' <br />I"resno,CA 93722 b� <br />(888)783.7422 <br />T3/OST22 Nip` <br />8B. Altemate Faculty. <br />Ststicycle, Inc. <br />90 N. Foxboro Drfire <br />North Salt Lake, CIT 84054 <br />(868)783.7422 <br />3A-448-.1{36 <br />TREATMENT FACILITY: t certify that I have been authorized by the <br />received the above Indicated wastes In accordance with the requiter <br />Pnnt/Fype Name Signature <br />8C. Alternate Feditty: <br />Starlcycle. Inc. <br />1651 Shelton Drive <br />Hollister, CA 95023 <br />(S68)7M7422 <br />TSIOST 83 <br />8D. Alternate FacnlW. <br />Ster)cycle, Inc. <br />3140 N 7th Streettrty <br />Kansas Gill, KS 66115 <br />(866)783-7422 <br />TWOST 26 <br />icable state agency to accept untreated medical wastes and that I have <br />outlined In that authorization. <br />I <br />Ft <br />