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<br />Y MEDICAL WASTE TRACKING FORM'NUMBER
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800424-9300 STANDARD MANIFEST 001-1GVG-STO
<br />Route #: 123 — 13 CUSTOMER NO. 21132 NjQFROOHXUT
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CALIr RNiA ST
<br />STOCRTON, CA 95204- 6117
<br />6.2, PGII
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment ate fully and accurately TOTALS ® 5'.q
<br />dawribed above by the proper shipping name, and are classified, padcaged, marked and labelled/placarded, a
<br />are in all respects in proper condition for transpoto applicabt International Vrnland nationa7irn
<br />latlone
<br />n�_,_�rn._�� 1 I A VZYCO-011
<br />ammf Data
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />a 4135 V. Swift Ave
<br />Freano,cA 93722
<br />a TRANSPORTER CERTIFICATION: R of
<br />[] This is a
<br />medical waste as described above
<br />Phone #: Pe 8 IVdmba3-7422
<br />Shipment Applicable ers
<br />Hauler Re" 3800
<br />Dale
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS. (j Phone #. i
<br />Fri a r Applicable Permit Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical roasts as described above
<br />Pdnt/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #•
<br />IApplicable Pemut Numbers:
<br />00 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrintRype Name Signature Date
<br />j
<br />[7REPANCY INDICATION
<br />+I 4'
<br />9
<br />I
<br />eA. Designated Facility:
<br />CUSTOMER NUMBER 6111852-001.,.----GENERAioirsRsoisutAiION#
<br />JU BC. Alternate Facility. I -I 80 Alternate Faculty:
<br />2A. DESCRIPTION OF WASTE 211. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />4136 W. it; Ave
<br />N. Foxboro D&e
<br />CONTAINERS
<br />I=fS6ittd a7x7 %(�
<br />A9►0
<br />IroitlTa4attWkee tli &IQs3'i
<br />UNU91 Regulated Medical Waste, n.o s.,
<br />6,2, 14811TB05 - 40 tial Tub (13io) (S.3 cn ft)
<br />{868)78 22` {.V16
<br />CU Ft
<br />(866)783-7422
<br />. PGPGII Regulated Medial Waste, u o.s ,
<br />66.2 T84 9 - 37 Gal Tub (eio) (4.9 Cu f t)
<br />.2,
<br />aA.448,1436
<br />Cu FL
<br />®
<br />66.2. PGl1 Regulated Medical Waste, n.os., TB14 - 44 Gal Tub (Bio) (S.9 Cu ft)
<br />PrIntPType Name
<br />Cu FB
<br />Date
<br />U232291 Regulated Medial Waste, n o.s., TB21- (BSO) /Te15- (Path) /TY15- (Chemo) 20 Gal Tub (2.7C
<br />)
<br />Cu Fl
<br />W
<br />W4
<br />UN32s1 Regulated Medial Waste, nor,,
<br />6.2, Pell WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gel Tub .14C
<br />T)
<br />Cu Ft
<br />82. POIJ Regulated Medical Waste, n.os , WB43- (Bio) /PW43- (Path) /CWIt3^ Chemo Gal Tub 5.7CUFT
<br />Cu FL
<br />6.2. P811 Regulated Medical Waste, n.o.s., RRB - Biosystems Cardboard Box 4.2 cu ft)Cu
<br />FB
<br />UN3291, Regulated Medical Waste, n,a s,
<br />6.2, PGII
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment ate fully and accurately TOTALS ® 5'.q
<br />dawribed above by the proper shipping name, and are classified, padcaged, marked and labelled/placarded, a
<br />are in all respects in proper condition for transpoto applicabt International Vrnland nationa7irn
<br />latlone
<br />n�_,_�rn._�� 1 I A VZYCO-011
<br />ammf Data
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc.
<br />a 4135 V. Swift Ave
<br />Freano,cA 93722
<br />a TRANSPORTER CERTIFICATION: R of
<br />[] This is a
<br />medical waste as described above
<br />Phone #: Pe 8 IVdmba3-7422
<br />Shipment Applicable ers
<br />Hauler Re" 3800
<br />Dale
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS. (j Phone #. i
<br />Fri a r Applicable Permit Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical roasts as described above
<br />Pdnt/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #•
<br />IApplicable Pemut Numbers:
<br />00 INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrintRype Name Signature Date
<br />j
<br />[7REPANCY INDICATION
<br />+I 4'
<br />9
<br />I
<br />eA. Designated Facility:
<br />U 8e. Allemale Facility:
<br />JU BC. Alternate Facility. I -I 80 Alternate Faculty:
<br />Sterlclydt'�, tt ^INE OlxtTz
<br />Stertcycle. Inc.
<br />Stericycle. Inc.
<br />4136 W. it; Ave
<br />N. Foxboro D&e
<br />1651 Shelton Drtve
<br />I=fS6ittd a7x7 %(�
<br />A9►0
<br />IroitlTa4attWkee tli &IQs3'i
<br />f It:Ilhr. CA 95II23
<br />{868)78 22` {.V16
<br />(866)783.7422
<br />(866)783-7422
<br />TSIOST22
<br />aA.448,1436
<br />TWOST W
<br />TREATMENT FACILITY: 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 />PrIntPType Name
<br />Signature
<br />Date
<br />Transferred containers, ou Q to
<br />n
<br />ca
<br />i
<br />
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