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®oi® tericycle* IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 <br />j ° p0 �o�P� w9 'Knee}a <br />-A- l tpl ,. l r, CUSTOMER NO. 21132 <br />1. Generator's Name, AT: and Telephone Number <br />AL N: <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOMM11, DA 95204- 6117 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10-WSTD <br />EI IIIIII�I�NIIInIRINIbI�INI�I <br />GENERAT OWS RECe MATtoN A <br />CONTAINER TYPE <br />TB49 - 37 Gal. Tub (Bio) (4.9 cu ft) <br />T814 - 44 Gal Tub(Bio) (5.9 Cu TV <br />TB21-(BIO)/TP15-(Fath)/TYi5-(Chemo)20 Gal Tub(2.7C <br />NB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 coal Tub(4.14 <br />20. NO. OF 12M VOLUME <br />CONTAINERS <br />UN3291; Regulated Medical Waste, n.o s.,l I I I <br />E <br />4. <br />X0 <br />Q a Ti <br />t$ <br />ten rator's Cart cation, 1 hereby declare that the contents of this consignment are fully and aura fy <br />above by the proper shipping name, and are classified, pacgaged, marked and labelled/ rd , and <br />In a I aspects in proper condition for transport according to applicable international and na i en <br />77 <br />P tednyped Name YtLane, natur <br />IANSPORTER 1 ADDRESS: <br />StexicyGle, Inc. ® This is a Through <br />4135 W. Swift Ave <br />Flreano,CA 93722 <br />iNSP®RTF1R-CERTiFlCA : Receipt of medical waste as ldescwaz�'�� <br />mtRype Name <br />am2mmr==1 <br />Phone #: �®q 783-7422 <br />Applicable sit sitars <br />Hauler Reg# 3400 <br />CummER NUMBER 61 <br />ne . <br />2A. DESCRIPTION OF WASTE <br />UN3291, Regulated Medical Waste, n <br />6.2, PGII <br />U2PG111 Regulated Medical Waste, a <br />O <br />Chi Regulated Medical Waste, n <br />6023 <br />a <br />UN3291 Regulated Medical Waste, It <br />6.2,1361 <br />CC <br />Phone !i: <br />W <br />UN3291 Regulated Medical Waste -,n <br />6.2, PGI1 <br />W <br />0 <br />cUN322991i Regulated Medical Waste, n <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10-WSTD <br />EI IIIIII�I�NIIInIRINIbI�INI�I <br />GENERAT OWS RECe MATtoN A <br />CONTAINER TYPE <br />TB49 - 37 Gal. Tub (Bio) (4.9 cu ft) <br />T814 - 44 Gal Tub(Bio) (5.9 Cu TV <br />TB21-(BIO)/TP15-(Fath)/TYi5-(Chemo)20 Gal Tub(2.7C <br />NB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 coal Tub(4.14 <br />20. NO. OF 12M VOLUME <br />CONTAINERS <br />UN3291; Regulated Medical Waste, n.o s.,l I I I <br />E <br />4. <br />X0 <br />Q a Ti <br />t$ <br />ten rator's Cart cation, 1 hereby declare that the contents of this consignment are fully and aura fy <br />above by the proper shipping name, and are classified, pacgaged, marked and labelled/ rd , and <br />In a I aspects in proper condition for transport according to applicable international and na i en <br />77 <br />P tednyped Name YtLane, natur <br />IANSPORTER 1 ADDRESS: <br />StexicyGle, Inc. ® This is a Through <br />4135 W. Swift Ave <br />Flreano,CA 93722 <br />iNSP®RTF1R-CERTiFlCA : Receipt of medical waste as ldescwaz�'�� <br />mtRype Name <br />am2mmr==1 <br />Phone #: �®q 783-7422 <br />Applicable sit sitars <br />Hauler Reg# 3400 <br />ORIGINAL <br />S. INTERMEDIATE HANDLER2/TRANSPORTER 2ADDRESS. <br />ne . <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinMpa Name Signature <br />Date <br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone !i: <br />H® <br />Applicable Permit Numbers: <br />0 1 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFIC4TION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />}RteAa <br />f netsd Facility: OSS.AlternatelFacility. ❑ 80. Alternate Facility: <br />® 80. Alternate Facility <br />Sterlcycle, Inc.ftrlcyde. Inc. SWricycle, Inc. <br />4185 W. Swat 90 N. Foxboro Drive 1651 Shelton Drive <br />Fresno.oo <br />North Salt Lake, UT 84054 Hollister, CA 95023 <br />h <br />(866)78& 2 i�®'�� (865)783-7422 (866)783-7422 <br />Iz <br />TSICIM22 %16 SAA48 W36 TS/4ST 83 <br />R <br />AQ� <br />TREATMENT FACILITY: I I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above Indicattwastes in accordance with the requirement outlined in that authorization. <br />Print type Name Signature <br />Date <br />Transferred contalners, CU a to <br />4 <br />ORIGINAL <br />