Laserfiche WebLink
o;.;a $$ericyClee <br />P"W"Poop$a:do MRi,k: <br />ti <br />r <br />MEDICAL. WASTE TRACKING FORM NUMBER <br />IN�OAS EMER�a ICY COIJ�gCT: CtiEMTREC TOMER NO.2 132 STANDARD <br />M FROOHU3Q MANIFEST &8TD <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL ME131CAL CENTER <br />1.617 N CALIFORWIA ST <br />STOCKMV, CA 95204- 6117 <br />(209) 451-9031 5/17/2016 . <br />CUSMMER NUMBER (51118,92-001 GENERAToW s REGlammom # <br />2A. DESCRIPTION OF WASTE <br />2B. CCNTAtNERTYPE 2C. No. of <br />2D. VOLUME <br />CONTAINERS <br />ON3291 Regulated Medical Waste, n.o.s., <br />6.2, PGIS <br />T$05 — 40 tial Tub (Bio) (5.3 cu it) <br />Cu Ft <br />&2315 Regulated Medical Waste, n.o.s., <br />T049 — 37 Gal Tub (Bio) (4.9 Cu ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n o.s., <br />6.2, 1`1311 <br />T414 — 44 Gal Tub (Bio) (5.9 Cu ft) <br />P Cu R <br />UN329t Regulated Medical Waste, n.o.s., <br />6.2, P611 <br />— 1 T — n TY — e mo Gal T CUF <br />Cu R <br />UN GiEi Regulated Medical Waste, rixs, <br />14831— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4.140 T) <br />Cu Ft <br />UN3 9115 Regulated Medical Waste, n o s., <br />9x843— (Bio) /PW43— (Path) /CW43— (Chemo) eal Tub (5.7CUFT) <br />Cu Fl <br />UII Regulated Medical Waste, nos., <br />KU— Biosystems Cardboard Box (4.2 Cu ft) <br />Cu Ft <br />UN329 <br />Regulated Medical Waste, aos ,62, <br />II <br />Cu F t. <br />Regulated Medical Waste, n.os., <br />6UN�3299l5 <br />Cu Ft <br />3. G nerator's Certification: "I hereby declare that the contents of thus consignment are fully and aceu rely TOTALS' C Cu Ft <br />des above by ft proper shipping name, and are classified, packaged, marked and labeged/placa ad, and <br />ar respects In proper condition for transport according to applicable International and nahor v MmAn egUla - <br />d Name �I VS.`/3lgnatury/ <br />I ADgerSiCyCle, Inc. 0 This is a Through <br />4135 2. Swift Ave <br />Franno,CA 53722 <br />4-@ERTt FCA : Reoe,pt of medical waste as descn <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />N <br />am <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />— Pdnt/fype Name Signature <br />Q <br />esignated Facility: 01 <br />Stericycle, InK22� <br />00- <br />4136 W. SVVI <br />Fresno,CA 9 <br />Uj <br />.r <br />w <br />Phone# (tirob) ltf.S— rgzi <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date. 5-[7 <br />Phone M <br />Applicable Permit Numbers• <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS' Phone # <br />W Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medial waste as described above. <br />T <br />PdnV4" Name Signature Date <br />7. DISCREPANCY INDICATION <br />TS14ST227a22 0 <br />88. Alternate Facility: <br />Sterlcycle, Inc. <br />80 N. Foxboro Drive <br />North Sett Lake, UT 84054 <br />(866)783-7422 <br />3A-448-JAr36 <br />8C. Alternate Faculty <br />Stedcycle, Inc. <br />1651 Shelton DrIve <br />Hollister, CA 95023 <br />(866)783-7422 <br />TS/OST 83 <br />8D. Altemete Facility: <br />TREATMENT l=ACiLITY. 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 />PrinVfypo Name Signature Date <br />ORIGINAL <br />