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° } MEDICAL WASTE TRACKING FORM NUMBER <br />0®.60 ter icyCie° IN CASE OF EMERGENCY CONTACT: CHEMTREC 9-800.424.9300 STANDARD MANIFEST 001.10-06•STD <br />° hawc ftapu ace ext toUte . 123 — 15 CUSTOMER NO. 21132 MDFR0014 E8 <br />1. Generators Namess and Telephone Number <br />ATTN <br />GILL 14MAICAL CENM}j IF dI !1 <br />1617 N CALXFCRNIA ST <br />STOCKZ3I, CA 95204- 6117 <br />(209) 4S1-9031 8/2/2016 <br />021 <br />1 <br />rz <br />a <br />CusTomFRNumsER 6111852-001 GENERATOWSREGNTRATION# <br />2A. DESCRIPTION OF WASTE 20. CONTAtNERTYPE 20. NO. OF 20. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., TBOS — 40 tial Tub (Bio) (5.3 cu ft) CONTAINERS <br />6.2, PGIJ Cu Ft. <br />UN3291 <br />N3 911i,Regulated Medical Waste, n.o.s., TB49 — 37 Gal Tub (Bio) (4.9 cu ft) Cu F4 <br />UN32911 Regulated Medical Waste, n.o.s., TB14 — 44 Gal Tub (Bio) (3.9 cu ft) <br />UN3291 Regulated Medical Waste, U.S, kremnr ! s ssa— %%exaeaav! <v W.. ..... o c.+.sa I r <br />62, Pal C <br />UN3291, Regulated Medical Waste, n.o s., p,1B31— (Bio) /WP31- (Path) IWC31— (Chemo) 31 Gal Tub (4.140 T) <br />6.2, PGII <br />C <br />6.22. palj Regulated Medical waste, n.o.s., <br />6WB43— (Bio) /PW43— (Path) /CW43— (Chemo) Gal Tub (5.7CUPT) <br />UN3291, Regulated Medical Waste, n.os„ XRE — Biosystems Cardboard Box (4.2 cu ft) C <br />6.2, Poll <br />UN 6� Regulated Medical Waste, n.os., C <br />UN3291 Regulated Medical Waste, no a, G <br />62, Pali <br />► <br />3. ie's 's Certlflcstlon: "1 hereby declare that the contents of this consignment are fully and accTOTALS urately C <br />scnbed ab ve by the proper shipping name, and are classilled, padagjad, marked and labelled/placarded, and <br />are In all respects in proper rendition for transport according to applicable mternahonal and national governme tai re f Goes° 7 <br />A3Printe&%edName `, Qw, k- `&0 Signature <br />4.T ORTER 1 AC KESS: ® Phone #: <br />Stericycle, Inc. This is a Through Shipment <br />4135 W. Swift: Ave Applicable Permit Numbers:g# <br />Fcesno,CA 93722 Saulelc Re3400 <br />TRANSPORTER CER ATION: Receipt of medical waste as <br />SW s a <br />Print/fyps Name S St wee Data <br />5. INTERMEDIA <br />g0 <br />i INTERMEDM <br />Pflntltype Name <br />6.INTERMEDIAI <br />1-9 <br />r <br />w <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as dumbed above. <br />Signature <br />HANDLERS /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers, <br />Data <br />Phone #: <br />Applicable Paring Numbers - <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpi of medical waste as described above. <br />Pdm/lype Name Signature Date <br />e. umurrerAr4uY INDa:ATION <br />uosrgnami; Facility: L j as. Altemate FacNly JLJ 80. Attemate Faclaly: ® 80. Altemate Faculty: <br />SWf'Cyale, !fig S rIcycle, Inc. Stericycle, Inc. <br />4135 W. 51 'J NE 90 N. Foxboro Dove 1661 Shelton Drive <br />Freano,CA 93722 North Salt Lake. UT 84054 Hollister, CA 95023 <br />(866)70.7 a02 2016 (866)783-7422 (866)783-7422 <br />T22 <br />T310SU448-.JA-36 TSIOST 83 <br />TREATMENT RACILITY: I certlwat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined in that authorizabon. <br />Printlfype Name Signature Date <br />cans erre cornanim, <br />ORIGINAL <br />milli <br />