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<br />Aft MEDICAL WASTETRACKING FORM NUMBER
<br />SE t O EMr €NCY CjrCT: Ci1EMTREC 1-800-024- STANDARD MANIFEST 001 -10.06 -STD
<br />e b i CUSTOMER NO. 21 . - MDL' ROO LMI P
<br />1. Generator's Name, Address and Telephone Number
<br />ATT:
<br />GILL IVEDICAL CENTIER
<br />1017 N CALIFORNIA ST
<br />STOCMN, CA 85204- 0117
<br />iiimiisrmuoiiiamii�ud
<br />(209)451-8031
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGIMATION 0
<br />2A. DESCRIPTION OF WASTE2B. CONTAINER TYPE 2C. NO, OF 20.
<br />UN3291, Regulated Medical Waste, n.os., T804 _ 28 Gal Tub (Bial (3 7 cu IIICONTAINERS
<br />TBl4 _ 37 Gal Tub (Bial (4.9 cu 1!)
<br />r7
<br />W8434_--"434--)NVC434---j Gal Tub(5.7CUFT)
<br />KR— . Bi ems Cardboard Bax (4.3 cu 2)
<br />3. Generator's CerthIcation: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />aspects in proper oondition for transport according to applicable international and natior~rnmental regulations."
<br />P ' ted/Typed Name r
<br />PORTER 1 ADDRESS: Inc. '
<br />4` 1135 t This
<br />2 IL F ,CA 93722
<br />IE
<br />Z TRANSPORTER CERTIFICATION: Receipt of medical waste as descr a
<br />Print/Type Name Signature
<br />0
<br />IN
<br />Phone N: (S01i)Tw-r42
<br />ShiQmelt
<br />Applicable Permit Numbers:
<br />Hauler Rog# 3400
<br />Date ----`5-- (
<br />Cu Ft.
<br />.,
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />Phone A:
<br />6,2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />PGII
<br />M
<br />062,
<br />Regulated Medical Waste, n,o.s.,
<br />QUN3291,
<br />IM
<br />6.21 PGII
<br />UN3291Regulated Medical Waste, n.o.s„
<br />62, PGII
<br />W
<br />2
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Phone M:
<br />�' 01?I
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />Brooks, OR 97345
<br />Print/Type Name Signature
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />(866)7x3-7422
<br />TBl4 _ 37 Gal Tub (Bial (4.9 cu 1!)
<br />r7
<br />W8434_--"434--)NVC434---j Gal Tub(5.7CUFT)
<br />KR— . Bi ems Cardboard Bax (4.3 cu 2)
<br />3. Generator's CerthIcation: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />aspects in proper oondition for transport according to applicable international and natior~rnmental regulations."
<br />P ' ted/Typed Name r
<br />PORTER 1 ADDRESS: Inc. '
<br />4` 1135 t This
<br />2 IL F ,CA 93722
<br />IE
<br />Z TRANSPORTER CERTIFICATION: Receipt of medical waste as descr a
<br />Print/Type Name Signature
<br />0
<br />IN
<br />Phone N: (S01i)Tw-r42
<br />ShiQmelt
<br />Applicable Permit Numbers:
<br />Hauler Rog# 3400
<br />Date ----`5-- (
<br />Cu Ft.
<br />.,
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone A:
<br />a
<br />®8D. Albmeb Feclllty:
<br />Applicable Permit Numbers:
<br />Sbe We. Inc. (Auboc )
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Stericycle, Inc. (Autoclave)
<br />Covsnts Matlon, Inc
<br />Printlfype Name Signature
<br />Date
<br />90 N, Fo>foro &A
<br />1561 Shelton DM
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone M:
<br />�' 01?I
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable Permit Numbers:
<br />Brooks, OR 97345
<br />Print/Type Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
<br />rf2$A.
<br />De819nated Facility:
<br />8C. Alternate Facility:
<br />®8D. Albmeb Feclllty:
<br />-j
<br />Sbe We. Inc. (Auboc )
<br />Stsrlcyde, Inc.fIncinorator)
<br />Stericycle, Inc. (Autoclave)
<br />Covsnts Matlon, Inc
<br />v i
<br />4186 W, SwIlt Ave
<br />90 N, Fo>foro &A
<br />1561 Shelton DM
<br />4860 Brooldake Road NE
<br />4
<br />�' 01?I
<br />North l n1a,11T 94dQ4
<br />HcM5t r, CA 95023
<br />Brooks, OR 97345
<br />(at3d)7
<br />(at) ipm 1171
<br />(866)7x3-7422
<br />(605)393-0890
<br />wli-
<br />-22
<br />8,UW36
<br />TMST -83
<br />Permit A 364
<br />a
<br />r-0 15 2019
<br />IL
<br />TREATMENT AIL ' I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F
<br />received the ted wastes
<br />received
<br />in accordance with the requirement
<br />outlined in that authorization.
<br />Ln
<br />Name
<br />Signature
<br />Date
<br />,
<br />Transforlivill
<br />eu N to : ro.
<br />cu fl to : N. Sak Lake, UT
<br />
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