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.® <br />ftma"a..4.• <br />0 to <br />IN CASE OF EMERGENCY CONTACT CHEMTREC 1-600.424-9300 <br />Route #: 123 — 12 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10 -o6 -STD <br />MDFROOHOBO <br />1. Generator's Name, Address and Telephone Number <br />AWN.- <br />WN:GILD <br />GILLMEDICAL CEHTER <br />1617 N CAI,T'ORNIA ST <br />STOCKTON, CA 95204- 6117 <br />(209) 451-9031 4/5/2016 <br />CUSTOMER Ab1MeER 6111852-001 SENERArnars REGIS RANON # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, a o a., <br />6.2, PGII <br />T11305 — 40 Gal. Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />Cu Ft <br />623PG II Regulated Medical Waste, n,os., <br />TB49 - 37 Gal. Tub (Bio) (4.9 cu tt) <br />Cu Ft <br />gr <br />6 23PGI� Regulated Medical Waste, n,os., <br />T1014 — 44 Gal Tub (Dio) (5.9 cu tt) <br />® <br />Cu Ft <br />Q <br />2 2299 11 1 Regulated Medical Waste, n,o.s., <br />TB21- (BIO) /TP15— (Path) /TYIS- (Chemo) 20 Gal Tub (2.7CUFT <br />cc <br />6 3 <br />Cu Ft <br />UN3291PGIRegulated Medical Waste, no s., <br />WB31— (si o) /WP31— ( Path) /WC31— (Chemo) 31 Gal TUb (4.14CUP) <br />Cu Ft <br />IZ <br />6.2. PGI 91 Regulated Medical Waste, n o.s.' <br />WS43— (Bio) /PK43— (Path) /CW43— (Chemo) Gal Tub (5.7CUFT) <br />Cu FL <br />6 23�ii �pulated Medical e. n o s., <br />XRB _ Biosystems Cardboard Box (4.2 cu ft) <br />Cu FL <br />I! Regulated Medical Waste, n.os., <br />B 2. <br />Cu Ft <br />UNMI Regulated Medical Waste, n,os., <br />6.2 <br />Cu Ft <br />3. Generator's Certification: °I hereby declare that the Contents of this Consignment are fully and accurately T®TALS ®1 t G <br />Cu Ft <br />desc above by the proper shipping name, and are classified, packaged, marked and labeller* ed and <br />a pacts In pmper condition for transport acoording to applicable international and national g ern a gulabons" <br />k <br />Pri d%ped Name g <br />SPoRTER 1 ADDRESS; Phone #: (866) 783-7422 <br />Stericycle, Inc. Ij TIXLS is a Through Shipment <br />Applicable Permit Numbers: <br />4135 t4. Swift Ave Hauler Reg# 3400 <br />N <br />Eresno,CA 93722 <br />"C Z <br />TRANSPORTER CERTIFICATION: Re pt of mel waste as described <br />C•�' <br />Pririmpe Name Signature Date <br />S. INTERMEDIATE HMOLER 2 0 RANSPORTER 2 ADDRESS: Phone # <br />N <br />Appimbte Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of me6oal waste as described above <br />PdnViype Name Signature Date <br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone # <br />Applicable Permit Numbers, <br />2 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />— <br />Printrrype Name Signature Date <br />7. DISCREPANCY INDICATION <br />8A. Designated Facniry: 80. Alternate Facility: 0 8C. Alternate Facility: ® 80. Alemate Faendy: <br />ricycle, Inc. Stericycle. Inc. Stlerbcycle, Inc. <br />a <br />4135 W. SWR Ave W* 90 N. Foxboro Delve 1551 Shelton Dfive <br />Fresno,CA 93 North Sett Lake. UT 84054 Hollister, CA 95023 <br />U. <br />`\'P <br />z <br />(866)783-7422 (866)783-7422 (866)783-7422 <br />� <br />� <br />TSIOST22 3A -448 -JA -36 MOST 83 <br />a <br />W01 <br />�7 <br />TREATMENT FACILITY: I c9 that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above Indicatec{ wastes In accordance with the requirement outlined in that authorization. <br />PdnUType Nave Signature Date <br />as <br />Transferred containers, ou ft to <br />cy <br />Q <br />