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" MEDICAL WASTE TRACKING FORM NUMBER
<br />Ic?*** -Stericycle• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-9300 STANDARD MANIFEST Dof•taoa•srD
<br />j h0t°u1P2'.Re6dqRoute #: 123 — 14 CUSTOMER NO. 21132 MDFROOH 9C
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully an ace iy TOTALS 10, Cu F
<br />above by the proper shipping name, and are classified, packaged, marked and labelledd, and
<br />/In all peels In proper dilion for transport according to applicable intemational and nate al en/�%�jI®re/gulations" //��/ /'-' (`a I
<br />Ste,ricycle, Inc.
<br />a 4135 V. Swift Ave
<br />dc 0
<br />X'realnla, CA 93722
<br />a TRANSPORTER TIFICATiOI - celpt of medical waste as
<br />Printrrype Name Slgnab
<br />This is a Through
<br />Phone # (866) 783-7922
<br />Applicable Permit Numbere-
<br />BauleE Reg# 3400
<br />5. INTERMEDIATE HA46LER 2 /TRANSPORTER 2 ADDRESS: Phone #,
<br />Appitcabie Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnUType Name Signature Date
<br />e. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS- Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />a Prfnttlype Name Signature Date
<br />11 17. DISCREPANCY INDICATION
<br />V
<br />designated Faciety:
<br />Steticycte, Inc.
<br />4135 W.
<br />Fresno,CA 98T22
<br />(866)78&7422 1=
<br />TS/OM2 -
<br />813. Altemete FaelOty:
<br />Stericyde. inc.
<br />90 N, Fftoro DrIva
<br />North Salt Lake, UT 84054
<br />(866)783-7422
<br />T 3Ar448-JA-36
<br />TREATMENT FACILITY; I certify that I have been authorized by the
<br />received the above indicated wastes in accordance with the requiter
<br />8C. Aftemate Factidy:
<br />S6erlcycle, Inc.
<br />1661 Shelton Drhfe
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />8D. Alternate Facility:
<br />leable state agency to accept untreated medical wastes and that I have
<br />outlined in that authorization.
<br />PdWrype Name Signature Date
<br />ORIGINAL
<br />1. Generator's Nate, Address and Telephone Number
<br />ATTN: i
<br />GILL MEDICAL CENTER
<br />1617 11 CALIFORNIA ST
<br />STOCKTON, CA 96204— 6117
<br />(209) 451-9031
<br />4/19/2016
<br />CUSTOMER NUM13ER 61118 e52 —Q 0 *1 GENERATOR'S REmsTRAnoN #
<br />2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />� 23PGI� Regulated Medical Waste, no TBOS — 40 .Gal Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
<br />Cu FL
<br />UN3291 Regulated MRltcai Waate, n os ,
<br />6.2, PGI TB49 - 37 Gal Tub (Bio) (4.9 cut ft)
<br />Cu R.
<br />B 2, P61E Regulated Medical Waste, n.as., TB14 — 44 Gal Tub (Bio) (5.9 Cu tt)Cu
<br />Ft
<br />M
<br />UN3291 Regulated
<br />Regulated Medical Waste, n.O.&, TB21— (Bz®) /TPIS— (Path) /Tx15— (Chemo) 20 Leal Tub (2.7CUP'T
<br />6.2�
<br />Cu Ft
<br />Z
<br />6.2, PGII Regulated Medical Waste, UB31— (Bio) /WP31— `Path) /WC31— (Chemo) 31 Gal Tub (4.14CUr
<br />)
<br />Cu FL
<br />wUN3291
<br />Regulated Medical Waste, n.o a.,
<br />&Z PGI) WP43- (Bio) /PW43— (Path) /CW43— (Chemo) tial Tub (5.7CUPT)
<br />Cu R
<br />UN3291 Regulated Medical Waste, nos.,
<br />6.2, PGII MIB — Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, R.os.,
<br />_
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully an ace iy TOTALS 10, Cu F
<br />above by the proper shipping name, and are classified, packaged, marked and labelledd, and
<br />/In all peels In proper dilion for transport according to applicable intemational and nate al en/�%�jI®re/gulations" //��/ /'-' (`a I
<br />Ste,ricycle, Inc.
<br />a 4135 V. Swift Ave
<br />dc 0
<br />X'realnla, CA 93722
<br />a TRANSPORTER TIFICATiOI - celpt of medical waste as
<br />Printrrype Name Slgnab
<br />This is a Through
<br />Phone # (866) 783-7922
<br />Applicable Permit Numbere-
<br />BauleE Reg# 3400
<br />5. INTERMEDIATE HA46LER 2 /TRANSPORTER 2 ADDRESS: Phone #,
<br />Appitcabie Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnUType Name Signature Date
<br />e. INTERMEDIATE HANDLER 31TRANSPORTER 3 ADDRESS- Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />a Prfnttlype Name Signature Date
<br />11 17. DISCREPANCY INDICATION
<br />V
<br />designated Faciety:
<br />Steticycte, Inc.
<br />4135 W.
<br />Fresno,CA 98T22
<br />(866)78&7422 1=
<br />TS/OM2 -
<br />813. Altemete FaelOty:
<br />Stericyde. inc.
<br />90 N, Fftoro DrIva
<br />North Salt Lake, UT 84054
<br />(866)783-7422
<br />T 3Ar448-JA-36
<br />TREATMENT FACILITY; I certify that I have been authorized by the
<br />received the above indicated wastes in accordance with the requiter
<br />8C. Aftemate Factidy:
<br />S6erlcycle, Inc.
<br />1661 Shelton Drhfe
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />8D. Alternate Facility:
<br />leable state agency to accept untreated medical wastes and that I have
<br />outlined in that authorization.
<br />PdWrype Name Signature Date
<br />ORIGINAL
<br />
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