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MEDICAL. WASTE TRACKING FORM NUMBER <br />p; ®® Stei1Cycle® IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800 -424 -MG STANDARD MANIFEST 001-10-MSTD <br />• �"'°a° 8 <br />Route #: 123 — 16 CUSTOMER N0.21132 <br />1. Generator's Name, Address and Telephone Number 111111111111111 <br />!1ATPN°! I <br />GILL MEDICAL C39NM <br />1617 N CALI$iPtNIA ST <br />STOCKTON, CA 96204- 6117 <br />(209) 451-9031 5/3/2016 <br />CUSTOMER NUMBER --6111e 8 <br />2A. DESCRIPTION OF WASTE 28. <br />UN3291 Regulated Medical Waste, n.os„ <br />6.2, PGII <br />UN3291 Regulated Medical Waste, <br />6.2, PGII <br />® 6UN2 P i11� Regulated Medical waste, ri,o.s„ <br />QUN3291 Regulated Medical Waste, n,o.s., <br />j 6.2, PGII <br />W UN3291 Regulated Medical Wade, n,o.s., <br />z e2, PGI <br />UN32�911 Regulated Medical Waste, n.o.s., <br />Regulated Medical Waste, mos <br />nos <br />GENERAToFra ftsinswu%moN # <br />T805 - 40 Gal Tub (Bio) (5.3 s+u ft) <br />TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />TB14 - 44 Gal Tub(Bi*) (5.9 cu 2t) <br />TB21-(BxA)/TP1S-(path)/TY15-(Chemo)20 Gal Tub(2. <br />WB31-(Bio)/1WP31-(Path)/WC31-(Chemo)31 Gal Tub(4. <br />WB43- (Bio) /EW43- (Path) /CIW43- (Chemo) teal Tub (5.7C <br />ARB - Biosystetas Cardboard Box (4.2 cu tt) <br />S. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately I TOTALS <br />10, <br />de ed above by the proper shipping name, and are classified, packaged, marked and labelp/pllrCa ad, and <br />lrespects in proper col%%on for transport according to applicable international and n ntal regulations" <br />_���7P = a -tii'1�' ..."�:I 1L1�tii�2.�aAJ►t/L' t -'i , �r-liifi�'(r�ti �r•rr�a <br />�.. <br />SteCiCycle, Inc. 13 This :Ls a Through Stdipment <br />4135 V. Swift Ave <br />Fresno,CA 93722 <br />IF <br />TRANSPORTE."ERTITICAU: Receipt of mod" waste as described <br />1-7 <br />5 ', F <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS' ®.•/ <br />a <br />�B9 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Pdnf/rvDe Name Signature <br />!C. NO. OF 120. <br />CONTAINERS <br />VOLUME <br />r <br />Phoned: %W)-183-7422 <br />Applicable Permit Numbers, <br />Hauler Reg# 3400 <br />Data 5�' 3 In <br />•-(ham <br />Phone 0: <br />Applicable Permit Numbers' <br />Date <br />S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS' Phone #• <br />aj Applicable Permit Numbers, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnMpe Name Signature Date <br />7. <br />8 <br />Doslgnetad Facility: <br />88, Aaemate Facliity: <br />0 8C. Attemate Facility. ❑ 8D. Altemate Facility: <br />15) <br />Sterlcycte, Inc. <br />W. StfalR <br />Steri e. Inc. <br />Shericycle Inc. <br />1551 Shelton Ddn <br />w <br />4138 <br />90 N Foxboro Dr!" <br />FL <br />t=resno.CA <br />(866)7 <br />North Saft(.aige, UT 84054 <br />(866)783-7422 <br />Hollister. CA 95023 <br />(66W83.7422 <br />® <br />TS/09M®`3 <br />8,W <br />T9148T 83 <br />� <br />36 <br />9 <br />vl <br />THE FACILITY: I y blot 1 <br />have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br />I— <br />received the above indleat d wastes in <br />accordance with the requirement outlined in that authorization. <br />Print/We Name <br />Signature <br />Date <br />MM Transfbmd eaWners, cut to <br />CM <br />C.a <br />ORIGINAL <br />