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o'"®o Stericycle°
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1400.424-9300 STANDARD MANIFEST 001-10.05.370
<br />Route 0: 123 — 20 CUSTOMER NO. 21132 MDFROQHV20
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CALIFOIRNiA ST
<br />STOCKTON, CA 952014- 6117
<br />III IIIIIIIIIIIIIIIIIIII I IN IIIIIIIIIIIIII 11111111111111
<br />451-9031
<br />UN3291, Regulated Medical Waste, n,ris..
<br />5/24/2016
<br />!C. No. OF 21D. VOLUME
<br />CONTAINERS
<br />CUSMMERNUMBER 6111852r001 GENERAmG'RsREaiBTFi T=*
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<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />Phone 4
<br />c86Nurnber8 7922
<br />UN3291, Regulated Medial Waste, n o.s.,
<br />6.2, PGII
<br />TBO5 – 40 Gal Tub (Bio' (5.3 cu ft)
<br />Applicable
<br />6.2. PGli Regulated MedicalUifasta, n o s.,
<br />6.2, PG
<br />TB49 – 37 Gal Tub (Bio) (4.9 cu ft)
<br />I=
<br />UN3291 Regulated
<br />Ragulatad Medial waste, n as.,
<br />TB14 – 44 Gal Tub(Bio) (5.9 cu ft)
<br />4
<br />UN3291 Regulated Medial Waste, n,os.,
<br />6.2, PGII
<br />TB21– (Blit) /TP15– (Path) /TY1S– (Chemo) 20 Gal Tub (2.
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<br />IPtintnype
<br />Print/Type Name Signature
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<br />UN3291 Regulated Medial waste, n,o.s.,
<br />s.z, pGIi
<br />WB31- (Bio) /WP31- (Fath) /WC31- (Chemo) 31 Leal Tub (4.
<br />Phone It.
<br />B 2gPGii Regulated Medical Waste, n,o s.,
<br />WB43- (Bio) /PW43- (Path) /CW43- (Chemo) Gal Tub (5.7C
<br />Applicable Permit Numbers
<br />UN3291- Regulated Medial Waste, n,o.s.,
<br />6.21 Peri
<br />KPJ3— - Biosystems Cardboard Bose (4.2 cu ft)
<br />UN3291, Regulated Medical Waste, n,ris..
<br />5/24/2016
<br />!C. No. OF 21D. VOLUME
<br />CONTAINERS
<br />8. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accura ly I U to
<br />above by the proper shipping name, and are classlfted, packaged, and tabelled1placard d, and
<br />spects In proper condition for transport according to applicable international and national gove mental reguta Name nature
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<br />NSPORTER 1 ADDRESS;
<br />Phone 4
<br />c86Nurnber8 7922
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<br />Stericycle, Inc. This is a Through Shipment
<br />Applicable
<br />Q
<br />4135 w. Swift Ave
<br />N. Drive 1661 Shelton Drive
<br />North Salt Lake. Ur 84054 Hollister, CA 95023
<br />2
<br />Freisno, CA 93722
<br />Rauler Reg#p 3400
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<br />TRANSPORTEfLCEIRTIFICA tat ec9cat waste as d ad
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<br />Print/Type Name Signature
<br />Date " `�
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<br />S. INTERMEDIATE HANDLE 2/TRANSPORTER 2 ADDRESS-
<br />Phone It.
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<br />Signature Data
<br />Applicable Permit Numbers
<br />Transferred containers, cu 8 to
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Pnnt/lypa Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone C
<br />s g a:
<br />Applicable Peanut Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descrlbed above.
<br />PrInt/iype Name Signature
<br />Date
<br />,1.rastgnalod
<br />Faalltty:
<br />B8. Aliamate Facility: Ej 9C. Alternate Facility: ® SID. Aftemate FacilitySte
<br />cycle.Inc AobE ASE O
<br />4 Jae
<br />13 580
<br />Sterkyc(9. Inc. Stericycte, Inc.
<br />ruxboro
<br />U.
<br />Fresno,CA 93722
<br />N. Drive 1661 Shelton Drive
<br />North Salt Lake. Ur 84054 Hollister, CA 95023
<br />(888)783-742WY 24 20
<br />3422
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<br />Ts/4ST22
<br />(866)7833
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<br />TREATMENT FACILITY: i ci fy tha
<br />have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above Indicatetl wastes in accordance with the requirement outlined In that authorization.
<br />Name
<br />Signature Data
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<br />Transferred containers, cu 8 to
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