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MEDICAL WASTE TRACKING FORM NUMBER <br />Q •®!®o t • eriglic o IN CASE OF E ERG v CON T: CHEMTREC 14880-424-000 STANDARD MANIFEST 001 -10.06 -STD <br />�,� Route 1Nc3 -� cusroMER No. 21132 NdOFFiQOHPAA <br />1. Generator's Name, Address and Telephone Number <br />ATTN : <br />GILL WDICAL CEN'LM <br />1617 'N CAL11=111A ST <br />STOC Mw, CA 95204- 61317 <br />(209) 451-9031 <br />CusTomER NuMeaa 6111852-001 GENERATOR'S REOWMAT10N 0 <br />2A. DESCRIPTION OF WASTE 2B• CONTAINERTYPE <br />623 611 Regulated Medical Weals, n.o.s., TBOS - 40 Gal Tub (Bio) (5.3 cu tt) <br />UN329t Regulated Medical Waste, n 0.8, TB49 — 37 Gal Tub (Bio) (4.9 Cu ft) <br />6.2, PG11 <br />CC <br />UUN 291 Regulated Medical Waste, ".os., TB14 — 44 Gal. Tub (Bio) (5.9 Cu ft) <br />Q UN3291 Regulated Medical Wage, eos.. TB21— (BXD) TP15— (Pa ) TY15— C emo Gal Tab(277CMUF <br />a 6.2, PG11 <br />W UN3291 Regulated Medical Waste, a o s., WB3.1— (Bio) /WP31- (Path) /WC31— (Chemo)31 Gal Tub (4.14CU.. <br />W 6.2, PGII <br />62. Poll Regulated Medical Waste, n o s., WB63- (Bio) /PK43- (Path) /CW43- (Chemo) Gal Tub (5.7CUPT) <br />UN3291 Regulated Medical Waste,n.o.s., KRB — Biosystems Cardboard Box (4.2 cu ft) <br />6.2; PGI) <br />UN3291 Regulated Medical Waste, a os., <br />6.2,'PGI) <br />UN3291 Regulated Medical Waste, n.os., <br />6.2,,12611 <br />3. Generator's Certification: I hereby declare that the Contents of this consignment are fully and accurately TOTALS <br />d d above by the proper shipping name, and are classrhed, packaged, marked and laballed/placarded, rid <br />A <br />a1 espects In proper iti forr transport according to applicable International and national rn n u tudnt <br />rR"W3d :on,n AU 1 JAA& s,��tAfure /Vr <br />4/12/2016 <br />2C, NO. OF 12D VOLUME <br />CONTAINERS <br />SPORTER 1 ADDRESS ®a Phone 0 t D oo/ f t1.�— T �a6,s <br />CC 5teriGyfsle, zriC . This 3s aThr ug S aril Applicable Permit Numbers - <br />4135 Q. Swift Ave Hauler: Reg¢# 3400 <br />NIL Fresno,CA 93722 <br />off. ¢ TRANSPOR'T'ER IFICATION: rpt of I waste as described abo <br />F�- <br />PrtnVrype Name Signature Date <br />S. INTERMEDIATE HANDLER P. /TRANSPORTER 2 ADDRESS: Phone 0. <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbed above <br />PnnV7ype Name Signature Date <br />a <br />W <br />I— <br />IU <br />tit <br />w <br />LTJ <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone 4: <br />Applicable Permit Numbers, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICA71ON: Receipt of medfoal waste as described above. <br />PrinVNm Name Signature Date <br />7. DISCREPANCY <br />Designated Facility; <br />Stericycie, Inc. >c� <br />4135 W, Swift NO <br />Freano,CA 9377i' <br />6jlos= 22 INR 1`Z <br />80. Alternate Facility. <br />Stericycle, Inc. <br />90 N. Foxboro Drive <br />Nodh Suit Lake, LIT 94094 <br />(866)783-7422 <br />3A -448-.1A -36 <br />80. Alternate FaciBty: <br />Stericycle, Inc. <br />1661 Shelton Drive <br />Hollister, CA 83023 <br />(666)783.7422 <br />MOST 83 <br />BD.Atternate Facility: <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 />PdnVrype Name Signature Date <br />Cu <br />