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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424.9300 STANDARD MANIFEST 001.1010"M
<br />Route #: 123 — 14 CUSTOMER NO. 21132 MDFROO13GK
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MICAL CE
<br />161.7 N CALIFORVIA ST
<br />STOC=14, CA 95204— 6117
<br />11111111111161,0111111111111101,1111111111111111
<br />(209) 451-9031
<br />7/26/2016
<br />C. NO. OF 120. VOLUME
<br />CONTAINERS
<br />8 2, 91PalRegulates Medial waste, n.os, KRB r — g$otysts Cardboard Box (9.2 cu ft) CU Ft
<br />8 23201 Regulated Medical WaftR.O.L.
<br />Cu Ft,
<br />UN3291 Regulated Medical Waste, ams.,
<br />6.2, PGII Cu Ft
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS ® ` Cu Ft
<br />descr d above by the proper shipping name, and are ctassdued, packaged, marked and labeged/ -Ittided, ff
<br />ai spacts in
<br />proper
<br />1condition
<br />/ffor transport according to pitiable mtematconal and national g mm
<br />V 1 �l� 1c� _ _ I et : 4 k -Z r G�`
<br />a 4. TRANSPORTER 1 ADDRESS'
<br />Stericycle, Inc.
<br />4135 V. Swift Ave
<br />Fbesno,CA 93722
<br />ria Q TRANSPORTERF ATION• eoeipt of medical waste as
<br />PrinVrype Name SignaU
<br />Phone s• (860 783-7422
<br />Th1s :ter a Through Shigsaent Applicable Permit Numbers:
<br />Haulier Reg{► 3400
<br />Date
<br />CUSTOMER NUM13ER 6111852-001 QelaenATows Ri atMATION #
<br />Phone k.
<br />2A. DESCRIPTION OF WASTE
<br />20. CONTAINERTYPE
<br />Applicable Permit Numbers:
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />6.2, PGII
<br />TB05 — 40 Gal Tub (Bio) (5.3 cu ft)
<br />62,3 G11i Regulated Medical Waste, nos.,
<br />TB49 — 37 tial Tub (Bio) (4.9 cu ft)
<br />®
<br />6 232299 a1 Regulated Medical Waste, n,o.s.,
<br />TH14 _ 49 Dal g� (Bio) (5.9 Cu €t)
<br />Q
<br />a
<br />111113291Regulated Medial Waste. n.os.,
<br />6.2, PGII
<br />TB21— (133:0) /TP15— (Path) JTY15— (Chemo) 20 Qat. Tub (2.70UP
<br />W
<br />UN3291 Regulated Medical Waste, a as.,
<br />6.2, P61
<br />WB31— (bio) /WP31— (Path) IWC31— (Chemo) 31 Bal Tub (4.14CE
<br />tZ
<br />Cp
<br />62. PGII Regulated Medltaf Waste, nos.,
<br />W843- (Bio) /PK43— (Path) /c:if43— (Chemo) Gal Tub (5.7CUPT)
<br />7/26/2016
<br />C. NO. OF 120. VOLUME
<br />CONTAINERS
<br />8 2, 91PalRegulates Medial waste, n.os, KRB r — g$otysts Cardboard Box (9.2 cu ft) CU Ft
<br />8 23201 Regulated Medical WaftR.O.L.
<br />Cu Ft,
<br />UN3291 Regulated Medical Waste, ams.,
<br />6.2, PGII Cu Ft
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS ® ` Cu Ft
<br />descr d above by the proper shipping name, and are ctassdued, packaged, marked and labeged/ -Ittided, ff
<br />ai spacts in
<br />proper
<br />1condition
<br />/ffor transport according to pitiable mtematconal and national g mm
<br />V 1 �l� 1c� _ _ I et : 4 k -Z r G�`
<br />a 4. TRANSPORTER 1 ADDRESS'
<br />Stericycle, Inc.
<br />4135 V. Swift Ave
<br />Fbesno,CA 93722
<br />ria Q TRANSPORTERF ATION• eoeipt of medical waste as
<br />PrinVrype Name SignaU
<br />Phone s• (860 783-7422
<br />Th1s :ter a Through Shigsaent Applicable Permit Numbers:
<br />Haulier Reg{► 3400
<br />Date
<br />6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone k.
<br />a
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrIntflype Name Signature
<br />Dale
<br />COW
<br />li It
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone Ik
<br />Applicable Permit Numbers:
<br />IPHnVType
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Name signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />I noted Faolllty: ❑ 8B. Altemata Facnay: 8C. Alternate Facility:
<br />® 81). Alternate Facnity;
<br />-a
<br />a
<br />Steil St6r1cTIZ yc�e, Inc. Stericy le, Inc.
<br />4186 e ° 90 N. re.Drive 1551 sha tan DrNe
<br />u•
<br />Freano,CA 93722 North Salk Lake, UT 84054 Hollister, CA 99023
<br />Lu
<br />74
<br />791 j7 47 f 2016 4.44783.742z {8 TS8T 93 22
<br />TREATMENT FACILITY-:
<br />I candy that I have been authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />received
<br />the above indicated wastes In accordance with the requirement outlined In that authorization.
<br />Print/rype Name Signature
<br />'0a Date
<br />Transferred triers, GUN to
<br />O®
<br />j
<br />
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