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®® ®®te!"I .yc e! <br />.: <br />MEDICAL WASTE TRACKING FORM NUMBER <br />OEECYcorArCNEcuO24e332 srArMANIFEST <br />Qt srD <br />M M�FRQH <br />1. Generator's Name, Address and Telephone Number1111111 <br />AWN: !C 11 1l 11 1{ <br />GILL MEDICAL CEN M <br />1617 N CALUORNCA ST <br />mcxTow, CA 95204- 6117 <br />(209) 451-9031 6/28/2016 <br />3. Generator's Certification: `I hereby declare that the contents of this consignment are fully and a <br />described above by the proper shipping name, and are classified, packaged, marked and labelledrpl <br />are N all respects in proper cal n for transport \ according to applicable International and national <br />\D.lnlw.iRi.ww.d f.lww.w ll® ILJ' 1-V/R, QlnnnM <br />Q. TRANSPORTER 1 ADDRESS' <br />!r SteriCycle, Inc. Ttd9 is a <br />4135 W. Swift Ave <br />a Frexno,CA 93722 <br />rn <br />a a TRANSPORTERRjCERTIFICATION: Receipt of medical waste as described above. <br />P PrinVlypeName_ `l4A'LP1 V1/k7'-jXi Signature ^ 1 <br />VOLUME <br />V Date 1 lP— ''!V t <br />Phone #. <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date <br />5. INTERMEDIATE HANDLER 2 !TRANSPORTER 2 ADDRESS: ,/'r Phone 8 a / <br />Applicable Permit Numbers: <br />Qac <br />7 INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br />PrintPiype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #' <br />Applicable Permit Numbers: <br />callINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />— Print/Typo No Signature Date <br />7. <br />110 <br />11 <br />8A. Designated Facltlty: <br />4Stte W e. Inc. <br />EoWa <br />Freano,CA 93722 <br />(866)7&3- 1 28 2016 <br />88. Alternate Facility: <br />Stericycle, Inc. <br />90 N. Foxboro Odve <br />North Salt Lake. UT 84054 <br />(866)783-7422 <br />3A -448 -JA -38 <br />8Q Alternate Facility. <br />Stericycle, Inc. <br />1551 Shetton Drive <br />Hollister, CA 93023 <br />(866)783-7422 <br />TSIOST 83 <br />8D. Alternate Facility: <br />I I I <br />TENT FACIA : .hat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />the above indicated wastes In accordance with the requirement outlined in that authorization. <br />Name Signature Date <br />TrAllstaffea containers, au 9 to : <br />ORIGINAL. <br />CUSTOMER Numom 6111852-001 GENERATOR,s REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE 2C. NO. OF <br />UN3291 Regulated Medical Waste, mos., <br />6.2, PGII <br />TB05 - 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br />UN I Regulated Medical Waste, n.o.s., <br />x049 -� 37 Gal Tub (Bio) (4.9 CU. ft) f <br />1 <br />IT <br />8 32P1i Regulated Medical Waste, n.o.s., <br />TB14 - 44 Gal Tub (Bio) (5.9 Gu ft) <br />a <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGI! <br />a oto a <br />W <br />UN3291 Regulated Medical Waste, nos., <br />W031- (Bio) /WP31- (loath) /WC31- (Chemo) 31 Gal Tub (4.14C T) <br />Z <br />62, PGt1 <br />Lu <br />UN3291 Regulated Medical Waste, n.os., <br />WB43- (Bio) /PW43- (path) /CW43- (Chemo) Gal Tub (5.7CUFT) <br />itU02991 Regulated Medical Waste, n.o.s., <br />xRB� - Biosys:tems Cardboard Box (4.2 cu ft) <br />3. Generator's Certification: `I hereby declare that the contents of this consignment are fully and a <br />described above by the proper shipping name, and are classified, packaged, marked and labelledrpl <br />are N all respects in proper cal n for transport \ according to applicable International and national <br />\D.lnlw.iRi.ww.d f.lww.w ll® ILJ' 1-V/R, QlnnnM <br />Q. TRANSPORTER 1 ADDRESS' <br />!r SteriCycle, Inc. Ttd9 is a <br />4135 W. Swift Ave <br />a Frexno,CA 93722 <br />rn <br />a a TRANSPORTERRjCERTIFICATION: Receipt of medical waste as described above. <br />P PrinVlypeName_ `l4A'LP1 V1/k7'-jXi Signature ^ 1 <br />VOLUME <br />V Date 1 lP— ''!V t <br />Phone #. <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date <br />5. INTERMEDIATE HANDLER 2 !TRANSPORTER 2 ADDRESS: ,/'r Phone 8 a / <br />Applicable Permit Numbers: <br />Qac <br />7 INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br />PrintPiype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #' <br />Applicable Permit Numbers: <br />callINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />— Print/Typo No Signature Date <br />7. <br />110 <br />11 <br />8A. Designated Facltlty: <br />4Stte W e. Inc. <br />EoWa <br />Freano,CA 93722 <br />(866)7&3- 1 28 2016 <br />88. Alternate Facility: <br />Stericycle, Inc. <br />90 N. Foxboro Odve <br />North Salt Lake. UT 84054 <br />(866)783-7422 <br />3A -448 -JA -38 <br />8Q Alternate Facility. <br />Stericycle, Inc. <br />1551 Shetton Drive <br />Hollister, CA 93023 <br />(866)783-7422 <br />TSIOST 83 <br />8D. Alternate Facility: <br />I I I <br />TENT FACIA : .hat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />the above indicated wastes In accordance with the requirement outlined in that authorization. <br />Name Signature Date <br />TrAllstaffea containers, au 9 to : <br />ORIGINAL. <br />