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to <br />ORIGINAL <br />e MEDICAL WASTE TRACKING FORM NUMBER <br />Y g3 <br />00906 SterrleyClee IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424-00 STANDARD MANIFEss 001-10-MSro <br />° P"IftPa,Pie.neaud�gaLk Rothe #: 123 - 19 CUSTOMER NO. 21132 Mt)r' RQOME <br />1. Generator's Name, Address and Telephone Number <br />GILL MEDICAL CRYUR <br />1617 N CA11FORNIA ST <br />STOCKTON, CA 95204- 6117 <br />(209) 451-9031 7/19/2016 <br />CUSTOMER NNMeER 61"11852-001 GENERATosrs gEQlsTRATtoN 9 <br />2A. DESCRIPTION OF WASTE <br />26. CONTAINERTYPE 2C. NO. OF <br />21). VOLUME <br />UN3291 Regulated Medical Waste, n.os.,CONTAINERS <br />TB05 - 40 tial Tub (Bio) (5.3 cu ft) <br />6.2, PGij <br />Cu Ft <br />UN3291. Regulated Medial Waste, mos.. <br />62, PGII <br />TH4 9 r 37 tial Tufa (Bio) (4.9 cu ft) <br />I <br />Cu Ft <br />pO <br />023291PolRegulated Medical Waste, n.os., <br />TB14 - 44 Gal Tub (Bio) (5.9 cu tt) <br />Cu Ft <br />jT!R <br />UN3291 Regulated Medial Waste, n.o.s., <br />6.2, PGII <br />TB21-(BIO) TP15w Path TYi - (G emo)20 Gal Tub (2.7CUPT <br />Cu FL <br />W <br />eUN=1 Regulated Medial Waste, n.DA, <br />WB31- (Bio) /WP31- (Path) /NC31- (Chemo) 31 Sal Tub (#.14CtJF ) <br />Cu Ft. <br />623 6fj Regulated Medial este, n.os, <br />VS43_ (Ea.o) /FK43- (Bath)/Ci 43- (Cheerio) Gal Tub (S. 7CUFT) <br />Cu R <br />UN362, Poll 01 Regulated Medial Waste, n.os, <br />) -. Biosystems Cardboard Box (4.2 cu 1t) <br />Cu Ft. <br />UN3291 Regulated Medial Waste, n.o.s., <br />6.2, nil <br />Cu Ft <br />UN3229911Regulated Medical Waste, n.o.s., <br />6z P61 <br />Ou Ft <br />3. Generators Certification: °I hereby declare that the contents of this consignment are fully and accurAfely T®TALS ® c Cy Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/place ,and <br />e pools In proper condition for tranasppoort according applicable International and nako ental regulations" <br />_to <br />1 C' {� <br />Ari adriypad Name T ®a V lrh Q ` G Si re <br />a <br />.TRA RTER 1 ADDRESS: Phone 4. (866) 7 83- 422 <br />Ster10ye1e, Inc. 0 This is a Through Shipment <br />4135 A. Swift Ave Applicable Permit Numbers. <br />Hauler Reg# 3400 <br />Fresno,CA 93722 <br />aU <br />TRANSPOFITEBZERTIFICA ipt of medical waste as descnbr� 7 <br />~ <br />/ <br />PrinUrype Nama Signature Dat i <br />S. INTERMEDIATE LER 2 t SPORTER 2 ADDRESS: Phone 8. <br />N <br />ce <br />+� <br />{ <br />Applicable Permit NumbersIL <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. ,J <br />PdnViype Nam Signature Date I <br />cow <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone M f <br />u <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />- <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />misignated Facility: SO. ARemete Faell ty: sc Ansmata Ficin <br />Aj ® is = ❑ ED. Ansmate Faculty: J <br />-t 3 �IVV Nt ORTIZ StetiCycle, Inc. Sieticycte, Inc. <br />4136 W. <br />SVMftAve 90 N. Foxboro Drive 165IS <br />a Shelton Drive <br />e. Fresno.CA 99722 North Sett take. til' 84am Hotlleter, CA 95023 <br />(866)783ML2 19 2016 (86 783-7422 (866)783-7422 <br />w TS 08722 3A448 -JA -39 MOST 83 <br />I <br />cc TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />I- received the above Indicated wastes In accordance with the requirement outlined in that authonzation. <br />Prinvrype Name Signature Date <br />rave erre containers, co to <br />to <br />ORIGINAL <br />