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IJ MEDICAL WASTE TRACKING FORM NUMBER <br />I' �e�IJC de STANDARD MAN! f 06-10--W= <br />i, Q ®O i7 y ° IN 1�qU®�F EMERFY CONN: CHEMTREC 1-80tWt2493®0�F� it 4 i.l <br />e hawd hqh Rctu*, 1116 # G 1x CUSTOMER NO. 21132 <br />1. Generator's Name, Address ss and Telephone Number 111611 <br />GILL MEDICAL CZVM <br />1617 N CALIFORNIA ST <br />STOCICTON, CA 95204- 6117 <br />(209) 451-9031 715!2016 <br />CIA PMERNUMER 6111852-00 <br />GEMedAiOR'S Rr:GIsrRAnoN # <br />2A. DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C. NO. OF 20. VOLUME <br />1.111182911. Regulated Medial Waste, n.o s., T805 - 40 Gal Tub (Bio) (5.3 Cu ft) <br />CONTAINERS <br />6.2, PGII Cu Ft <br />62391 Regulated Medial Waste, n.os., TB49 - 37 Dal Tub (Bio) (4.9 Cu Tt) Cu Ft <br />W 6NM I. Regulated Medical Waste, n.o.s., TB14 - 44 Gal Tub (Bio) (5.9 Cu gt) Cu Ft <br />Q �f d poll Regulated Medial waste, n os., - - a - <br />oCCU R <br />W Uflf3� Repuiated Medlat 4Yaste, n as, 6 31- (Bio) /WP31- (Path)1KC31- (Chemo) 31 Dal Tub (4.14C T) <br />tZ 6.2, pGlb Cu Ft <br />6 2, cif Regulated Medial Waste, n o s., MB43- (Bio) /VW43- (Path) /CW43- (chemo) Gal Tub (S. 7Ct7FT) <br />Cu R <br />UFf <br />NN3291 Regulated Medical Wage,no.s., KRB - Siosystcems Cardboard Box (9.2 Cu it) <br />6.Z PGII6.2, 111 Regulated Medical Waste, n.os., Cu Ft <br />U11132911, Regulated Medial Waste, n.o s. <br />6.2, poll Cu Ft <br />3. Qe or's Carlificattom "I hereby declare that the contents of this consignment are fully and aaxlmiel 7®YACs �' ®- Cu R <br />des d a by the proper shipping name, and are classified, pacicaged, marked and labeile and <br />In, g res In proper condition for transport according to applicable international and na al g re tv, ulations" <br />Y _ . _ ®t t� ! t A L ` I t t/t /I _.�J tY <br />Phone #: savvl r w..— r,s-f-d, <br />I <br />AD e'r"icycle, Inc. This is a Through Ship t <br />0 4135 N. Swift Ave AppiknH Permit Numbers. <br />a Fresno,CA 93722 13au1es Rag# 3400 <br />2 <br />sn <br />a TRANSPORTE.,CERTIFCAT~eceipt of medical waste as described -� <br />PdnU7ype Name Signature Dale <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS- Phone fl: <br />em <br />Applicable Permit Numbers <br />2 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PnnvType Name Signature Date <br />q 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS. Phone C <br />I5 E Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />1Pr1nMpe Name Slgnatura Date <br />7. DISCREPANCY INDICATION <br />I <br />A Designated Facility: ®88. Alternate Facility. <br />® aC. Alternate Facility: aD. Altemate Facility: <br />cyal n N OFMZ Steticyale, Inc. <br />Statiicy*cle, Inc. <br />v <br />4136 W. 90 N. Foxboro Drive <br />1661 Shelton Dove <br />Freano,CA 93722 North Sett Lake, Lrr 84054 <br />Hollister, CA 85023 <br />(666)7834 2 ®5 2016 (SM7M7422 <br />(886)783-7422 <br />T9/t93T2r 3A-bA8-1A-3G <br />TS/039' 83 <br />XTREATMENT <br />o1recelved <br />FACILITY: I Cel°tity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />H <br />the above Indicated wastes In accordance with the requirement outlined In that authorization <br />Pnntrrype <br />Name Signature <br />Date <br />fe"I-I <br />rang --- mmainers, <br />Cut ft to <br />