Laserfiche WebLink
MEDICAL WASTE TRACICING FORM NUMBER <br />®® 5'itti"IC�/C�@° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424-93DD STANDARD MANIFEST 001 -10 -06 -STD <br />FMft( FM1&1 dA)gR Route #: 123 — 19 CUSTOMER NO. 21132 MDFRQQHVXO <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />163.7 N CALIFORNIA ST <br />STOCKTON, CA 95204— 6117 <br />(209) 451-9031 5/31/2016 <br />CusromanNuMaeR 6111852-001 GmEnAroiisRaalsm;moNf# <br />2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. NO. OF 21). VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., TB05 — 40 Gal Tub (Bio) (5.3 cu tt) CONTAINERS <br />6.2, PGII Cu Ft <br />UU23�'+ Regulated Medical Waste, n.o.s., TB49 — 37 Gal Tub (Bio) (4.9 cu ft) CU Ft <br />WUN PGII RRegulated Medial Waste, n.o s., TB14 — 44 Gal Tub (Bio) (S . 9 cu ft) I Cu FL <br />UN3291 Regulated Medical Waste, n.o s , A — etas a u(Z. irvun <br />fi.2, PGII Cu FL <br />LLI UN3291 Regulated Medlat Waste, no WB31— (Bio) /NP31— (Path) /WC31— (Chemo) 31. Gal Tub (4.14CU T) <br />111 <br />62, PGII Cu Ft. <br />I 6N3291 Regulated Medlret Waste, i.o s, W243— (Bio) /PK42— (Patin) /Cwa3— (Chemo) Gal Tub (5.7CUFT) <br />Cu Ft <br />I <br />UN3291 a Regulated Medical Waste, o.o s., KRB — Biosystems Cardboard Box (4.2 cu ft) <br />® Cu Ft <br />UN3291, Regulated Medial Waste, no s, <br />6.2, PGII Cu F <br />UN3291Regulated Medical Waste, n.o.s., F <br />6.2, PGIi Cu <br />3. arator's Certification: °I hereby declare that the contents of this consignment are fully and accurately TOTALS ® Cu Ft <br />Gbd above by the proper shipping name, and are classified, packaged, marked and Isbell rded, and <br />a in at respects In proper 00.0)on for transport according to applicable Intetnabonal and nand- ver- tai regulations <br />P tedllyped Name en, <br />4.T SPORiER 1 AO �es3cycle, Phone <br />Inc. � Th3.s is a Through Shipment <br />r # — <br />Applicable <br />Regi 3400 <br />Permit Numbers <br />4135 V. Swift Ave <br />O Frecno,CA 93722 Ha <br />aq TRANSPORTE ERTIFICATI : Receipt of medical waste as bed ve Gr ---1 t~~ <br />1-46 <br />PdntrPm Name Signatu Date <br />S. INTERMEDIAT ANDLE 2lTRANSPORTER 2 ADDRESS: Phonelig # <br />H Applicable Permit Numbers- <br />1163 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnVtype Name Signature Date <br />S. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 0- <br />5 Applicable Permit Numbers. <br />S 0 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ptfnt/'fype Name Signature Data <br />7. DISCREPANCY INDICATION <br />8A. Dosignated Pacnity: 89. Attemate Facility: 8C. ARemate Facility: ®eD. Attemate Facility; <br />Stericycle, Inc. ®le—' Stericycle, Inc. Stericycle. Inc. <br />4135W. 9O N. Foxboro Drtve 1551 Shelton Drive <br />Fresno,2 North Sall:Lake, UT 84034 Holllater, CA 85023 <br />(866)78M2.2' 106 (866)783-7422 (866)783-7422 <br />I IVOST220,,t `�'" 3A -448 -JA -36 MOST 83 <br />TREATMENT FACILITY: I Z;ertify 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 />I PdnVTWe Name — Signature Date <br />Transferred conialners, Cu Ulu <br />r <br />C7 <br />ORMM <br />