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rr --- --------- <br />MEDICAL WASTE TRACKING FORM NUMBER <br />Oval Steric pP� • IN 04lLdRF E J Y CdN I CT: GMEMTREC 1400-424STOMER lit). 27132 STANDARD�£°' �� 41T D <br />pmKft" <br />1. Generator's Name, Address and Telephone Number <br />A`CTN: jj I <br />GILL MEDICAL CE'HTER. <br />1617 N CALIFORNIA ST <br />STOCRTON, CA 95204- 6117 <br />(209) 451-9031 5/10/2016 <br />CUSTOMER NUMBER 6111852-001 GsraEFiAmamFlEoismAroN9 <br />2A. DESCRIPTION OF WASTS 2e. CONTAINER TYPE 2C. NO. OF 2D. VOLUME <br />TB05 — 40 Gal Tub (Bio) (5.3 cu ft) <br />UN329i Regulated Medical Waste, n o.s., CONTAINERS <br />82, Fall Gu Ft. <br />1N B291 Regulated Medical Waste, n.os., TB4 9 - 37 Gal Tub (HO) (4.9 cu ft) <br />8.2, Pali <br />Cu Ft <br />UN3291 Regulated Medical Waste, n,os, TB14 — 44 Gal Tub(Bio) (5.9 Cu ft) <br />62, P(111 Cu Ft <br />UN3291 Regulated Medical Waste, It -os' a — emo <br />8.2, PQIi <br />Cu Ft <br />13291 Regulated Medical Waste, n o.s , WB31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4GIJ.140 T) <br />Cu Ft <br />UN3291 <br />3229911 Regulated Medical Waste, n o s, WB43— (Bio) /PW43— (Path) /CW43— (Chemo) Qat Tub (S . 7CiWT) <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n,os., KRB — Biosystems Cardboard Box (4.2 cu tt) <br />16.2, PGtl <br />c,r Ft. <br />UN3291, Regulated Medical Waste, n.os . <br />3. Q r oes Certification: W hereby declare that the contents of this consignment are fully and <br />d ed by the proper 8"%'ng name, and are classified, packaged, marked and labelled <br />in all reacts n proper Condition for transport according to applicable international and natlog <br />PdnVTypo Mame <br />" e icyke, Inc. <br />4135 A. Swift Ave <br />Fretsnv,CA 93722 <br />I—MITIPICATION;_Romat of n <br />c ety I TOTALS Is- <br />, <br />,_. % cu F <br />car ed, and <br />I mmental regulations" <br />ate <br />Throcagh shipment Phone <br />Applicable Permit Numbers: <br />a S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS. �J <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUiype Name signature <br />M U, 6. INTERMEDIATE HANDLER $ /TRANSPORTER 3 ADDRESS: <br />Iia: <br />I� N <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print/lype Name Stonature <br />I <br />algnatea Facility: <br />Eftycle, Inc. CIV <br />4136 W. <br />Fresno,CA 722 <br />TBfOST224Q►� 1® <br />86. Anamate Facility: <br />Stericycle, Inc. <br />90 N, Fora Drive <br />North Salt Lake. UT 84054 <br />(866)783.7422 <br />SLA-448,JA-36 <br />8C. Altemato Facility. <br />Sterlcycle, Inc. <br />1661 Shelton Drive <br />Hollister. CA 96023 <br />(866)78&7422 <br />TS/OST 83 <br />Hauler: Reg# 3400 <br />Data <br />�� 46* <br />Phan If. <br />Applicable Permit Numbers. <br />Date <br />Phone t <br />Applicable Permit Numbers: <br />Date <br />8D. Aaemate <br />TREATMENT FACILITY. I certify that I have been authorized by the applicable state agency to accept untreated medlcai wastes and that I have <br />received the above Indicated wastes in accordance with the requirement outlined In that authorization. <br />Prinveype Name Signature Date <br />- ORIGINAL I <br />