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MEDICAL WASTE TRACKING FORM NUMBER <br />®®®® S'�ed yCItE® CtAi B F t NCY CQJV)ACT: CHEMTREC 1-600924-9300 STANDARD MANIFEST 00'1 -t0 -os -STD <br />. r,., 199 CUSTOMER Na 21132 MDFRO01I L3 <br />1. Generator's NamATTNress and Telephone Number !� � (' ( �1 f � � ! � j� t j� <br />GILL MEDICAL CEWM <br />1.617 N cnirc m ST <br />ST N, CA 95204- 6117 <br />(209) 051-9031 7/12/2016 <br />CUSTOMER NUMBER 6111852-001 GENERATOR'S RE13MTRATION If <br />E 2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE 2CONO. HOF ERS 2D. VOLUME <br />UN3291 Regulated Medical Waste, n.os., TB05 — 40 Gal Tub (Rio) (5.3 cu ft) Cu Ft <br />6.2, Pell <br />UN3291 Regulated Medical Waste, n.o,s., T949 — 37 Gal Tub (Bio) (4.9 Cu tt) <br />6.2, P811 Cu Ft. <br />® <br />UNS291, Regulated Medical Waste, n.o s, TB14 — 44 Gal Tub (Bio) (3.9 cu ft) <br />62, PGIi Cu FL <br />Q UUN�3131 Regulated Medical Waste, n.o s., TP — Pa —(C emo) 20 Ga Tub (2.7CUl±T pall Cu Ft <br />I W 'UN <br />2r Regulated Medial Waste, n os., W831- (Bio) /igp31— (Pa bh) /9TC31— (Chemo) 31 Gal Tub (4.14CUF } <br />W 6.2, P41j Cu Ft. <br />SN23PGIi Regulated Medllat Waste, n.o s., W843— (Bi.o) /PwA2— (path) /coF43— (Chemo) Gal Tub (5. UWT) Cu Ft <br />RN3a11 Regulated Medical Waste, o.os., ggB — Biosystema Cardboard Box (4.2 au ft) <br />rn Fr_ <br />3. Grinerator's Certification: °i hereby declare that the contents of this consignment are fully and accurately TOTAL$ ® <br />I I I a "7' Cu Ft <br />d bone by the proper shipping name, and are classified, packaged, marked and labelled/pfac arded, and <br />e in all spects in proper condition for transport according to applicable International and national govemm cal regWahons" <br />` � �Q®n <br />'�f <br />�qat)—119-1 Uw <br />Pd <br />r tednyped Name lure <br />PORTER f <br />aterIcyale, Inc. 0 T1313 3.s a Through shipmerrt <br />Phone s: (866) 783— 422 <br />4135 of. Swift Ave <br />Applicable Pamut Numbers. <br />Hauler Reg# 3000 <br />g CL <br />Freano,CA 93722 <br />off, <br />TRANSPORTE TIFIeceipt of meeical waste as descnb o <br />t <br />fQ� <br />~ <br />j <br />Prin a Name Signature <br />S. INTERMEDIATE HANI)l Elr2 MrNSPORTER 2 ADDRESS: <br />Date <br />Phone #. <br />., <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrnVrype Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone s: <br />1C <br />Applicable Permit Numbers: <br />o m <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as downbed above <br />x <br />Printf ype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />DeslanMed F801111y: 8B. Altemete Fsclnty: 8c. Altemeta Facility: <br />® 8D Alternate Facility: <br />rfcycle Inc. Stec! e, Inc. Sterfcy+cle, Inc. <br />4185 W. NEORTIZ 90 N. <br />Fftor* Orta 1561 Shetbon DrMe <br />Preano,CA 93722 North Salt lake, UT 84054 Holiieber, CA 95023 <br />(866)783- (886)783-7422 (866)783-7422 <br />TS/OST 12 2016 SA -44844-38 TS/OST 83 <br />ItTREATMENT <br />FACT T'!Y'r lfy that I have been by the to <br />authorized applicable state agency accept untreated medical <br />wastes and that I have <br />received the above Indicated wastes in accordance with the requirement outlined in that authorization. <br />PrnMps Name Signature <br />Date <br />eMalnem, cu ft fio <br />s- <br />8 <br />