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i 11 Stericycie- hotacUnp VeoptaRed�Hlag �: MEDICAL WASTE TRACKING FORM NUMBER It SF V4FF ffycv CONT§CT: CHEMTREC 1-800-4249300 STANDARD MANIFEST 001-10-06•STO CUSTOMER NO. 21132 MDFROOHYS5 Generator's Name Address and Telephone Number WiTN: GILL MEDICAL CL'XTER 1617 N CALIFORNIA ST STOCKTON, CA 95204- 6117 (209) 451-9031 6/21/2016 CUSWMER NUMBER 67.11852-001 GENERATOR'SREGISM'nONO 2A. DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3 01 Regulated Medical Waste, n.os., TBOS – 40 Gal Tub (Bio) (5.3 ou ft) CONTAINERS Cu Ft, UN3291Regulated Medical Waste, nos., TH119 – Gal Tub (Bio) (4.9 cu ft) Apall Ft UNNS291, Regulated Medical Waste, ri=, – uo (i3 O) (5 . cu ft) m Cu Ft PQI UN3291 Regulated Medical Waste, n.o.s.. `- 6.2, PQH Cu F 6.2 91'I Regulated Medical Waste, n o.s., 0 1 W – (Pa 111014.mi – (C o) 3Gal Tub (4.140 T) Cu Ft U1Y829t, Regulated Medici Waste, n.os., 91843– (Bio) /EW43– (Path) /CK42– (Chemo) Gal Tub (5.7CUFT) 82, PRII O: Ft, UN3291 Regulated Medical Waste, n.os., KR8 – Biosystems Cardboard Box (4.2 cu ft) _ Cu Ft 6.2, Pali UN3291 Regulated Medical Waste, n.o a, 6.2, POIJ Cu Ft UN3291, Regulated Medial Waste. n.o.s , 3. Generator's Certification. "I hereby declare that the contents of this consignment are fully and accurately T®TALS ® ® Cu FL de dbed above by the proper shipping name, and are classified, packaged, marked and labelledtplacarded, and n II respects In proper condition for transport according to applicable International and national Quem a reg , t h P ntedityped Name 1 y" t ' , atureL-1 / Date (A–Z I – K 4. PORTER i A Phone #: a L.Cycle, Inc. This is a Through Shti.pnt — �. ' 4135 V. Swift Ave Applicable Permit Numbers: go FXeeno,CA 93722 Hauler Reg# 3400 N a TRANSPOR ERTIFICATION: R cetpt of mel waste as described—'x f Prin"pe Name Signature Date —' ' .� S. INTERMEDIATE HANDLER /TRANSPORTER 2 ADDRESS: Phone t Pq av Applicable Permit Numbers: 8 11 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as de=bed above PrinYtype Name Signature Date 8. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. Phone 0: g Applicable Permit Numbers - INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above — Printftype Name Signature Date 7. DISCREPANCY INDICATION N. +r . 8A. Designated ftll)ty: Q 88. Altemete Facility: ®8C. Altomate Facittby: 80. Attemats Facility: 4185 W.�SWft V 9900 N Foxbom Inc. W Shelton Inc. Fresno,CA 93722 North Sat Lake. UT 84034 Hollister, CA 95023 (886) 31 2 2 21 2016 (866)763-7422 (866)783-7422 .JA -86 TWOST 83 ,aAA.At— TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above Indicated wastes In accordance with the requirement outlined In that authorization. PdlnUiype Name Stgnature Date ..a......vs-, cow ea aw .