|
DoslgneW Facility: EO�% U 80, Alternate Facility: u 8C. Alternate Facility: U8D. ARernate Facility.
<br />tsricycle, Inc. PO Siencycle,'%. Stericycle, Inc.
<br />4136 W, Sv slPAv�e " 90 N. Foxboro CIM 1561 Shelton Drhre
<br />a Freeno,CA 93722 ®6 North Salt Lake, UT 84GS4 Hollister. CA 95023
<br />W
<br />(M)783-7422 (868)783-7422 ®� (868)783-7422 (866)783-7422
<br />T OA 07
<br />-448-.A-3s T3108T 83
<br />aPal TREATMENT FACILITY: I certify that t have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I— received the above indicated wastes In accordance with the requirement outlined In that authorization.
<br />Pr)nMpe Name tit Date
<br />C '
<br />a
<br />®R[
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />Sterg IN�pVtpeggRp�Y CONTFP CHEMTREC 1.80024-9300 STANDARD MANIFOT 0MSTD
<br />O®O
<br />r MDFRQUQ
<br />h•tetdnq Wg CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1611 N CALIFORNIA ST
<br />STOCKTON, CA 95204— 6117
<br />(209) 451-9031 6/7/2016
<br />6111852-001
<br />CussotnaR NuMBE R GENERATOR% REmsTRA'noN #
<br />2A. DASCRIPTION OF WASTE
<br />28, CONTAINERTYPE 20. NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medial , n.o s.,
<br />TB05 — 40 Gal Tub (Bio) (5.3 Cu ft) CONTAINERS
<br />6.2, PGII
<br />Cu Ft
<br />Regulated Medical Waste, 0.0 s.,
<br />6N32912.
<br />a O CU
<br />�
<br />Cu Ft
<br />M
<br />0113291 Regulated Medical Waste, n.o s.,
<br />a 1.0 Cu
<br />®
<br />6.2, P81I
<br />` Cu Ft
<br />Q
<br />UN3291 Regulated Medial Waste, n o.s.,
<br />e FGIJ
<br />Cu Ft
<br />W
<br />UN3291 Regulated Med cal Waste, o.o.s.,x
<br />—
<br />6.2, PGI)
<br />Cu Ft
<br />tZ
<br />d, Regulated Medical Waste, n.c s.,
<br />ats0 —(na o)gMa —(En )CW43— (C emo) cue Tub CUFT)
<br />6UN3
<br />Cu Pit
<br />UN3291 RegA*dMedical Waste, a.os.,
<br />KRB — Biosystems Cardboard Box (4.2 Cil tx)
<br />6.2, PGIJ
<br />Cu F4
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />6.2, PGI/
<br />Cu F4
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />62, PRII
<br />Cu F
<br />3. Generator's Certification: W hereby declare that the contents of this consignment are fully and accurately TOTAL$ ® v Cu Fr
<br />described above by the proper stdppinq name, and are ciassified, packaged, itiarked and labeliedlp riled, and
<br />are^ respects In proper tion for transporttiling toapplicable international and nation g mmental uiattorm"
<br />r
<br />Pr ednyped Name Scatu
<br />T PORTER 1 ADRW.Ccyc3.e, inn • ® This is a Through Shipment P is #:
<br />4135 V. Splint Ave App"�etllLO% ' 3400
<br />4 a0.
<br />Freano,CA 93722
<br />N
<br />a z
<br />TRACe1SPORTE nF CA' ®�: ' cel t of medical waste as d a
<br />..r
<br />`--
<br />PrinVlype Name Signature Data
<br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #;
<br />N
<br />Applicable Permit Numbers -
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnVlype Name Signature Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />N
<br />Applicable Permit Numbers -
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVlype Name signature Date I
<br />DISCREPANCY INDICATION f
<br />,7,
<br />DoslgneW Facility: EO�% U 80, Alternate Facility: u 8C. Alternate Facility: U8D. ARernate Facility.
<br />tsricycle, Inc. PO Siencycle,'%. Stericycle, Inc.
<br />4136 W, Sv slPAv�e " 90 N. Foxboro CIM 1561 Shelton Drhre
<br />a Freeno,CA 93722 ®6 North Salt Lake, UT 84GS4 Hollister. CA 95023
<br />W
<br />(M)783-7422 (868)783-7422 ®� (868)783-7422 (866)783-7422
<br />T OA 07
<br />-448-.A-3s T3108T 83
<br />aPal TREATMENT FACILITY: I certify that t have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I— received the above indicated wastes In accordance with the requirement outlined In that authorization.
<br />Pr)nMpe Name tit Date
<br />C '
<br />a
<br />®R[
<br />
|