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MEDICAL WASTE TRACKING FORM NUMBER
<br />®i ®! ericycle` ASE QF EMERGENCY CONTACT: CHEMTREC 1800 42 STANDARD MANIFEST 001 -10.06 -STD
<br />#c 121"0 — 18 CUSTOMER NO. 2 MDFROOLL2V
<br />Transferred containers, c. ft I. Brooks,
<br />1. Generator's Name, Address and Telephone Number r
<br />A
<br />GILL MEDICAL CENTER
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031
<br />2!812019
<br />g
<br />CUSTOMER NUMBER 61 1 1 852-00) GENERATOR'S REGISTRATION M
<br />6111852-001
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291Regulated Medical Waste, n.o,s.,
<br />TB" - 28 Gal Tub (Bic) (3.7 cu 1t)
<br />CONTAINERS
<br />6.2, PGI)
<br />Cu Ft.
<br />6 23Poli Regulated Medical Waste, n.o.s.,
<br />TB49 - 37 Gal Tub (Bio) (4.9 cu R)
<br />Cu FI.
<br />M
<br />UN3291, Regulated Medical Waste, n.o.s.,14
<br />6.2, PGII
<br />44 Gal Tub Bl0 5.9 Cu }tl
<br />( ) (
<br />74Cu
<br />0
<br />!
<br />Ft.
<br />6 23PGII Regulated Medical Waste, n.o.s.,
<br />TB21 ) fTP11$„ (�tFTTY1C5-( )2Q Gal Tub(2.7CUFT)
<br />N J�
<br />�
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />W
<br />6.2, PGII
<br />Cu Ft.
<br />0
<br />6.2, PGIj Regulated Medical Waste, n.o.s.,
<br />WB434T}NVp434,_„)1WC434 _) Gal Tub(5.7CUFT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />KR_ - BiOS"ems Cardboard Box (4.3 Cu f!)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />PGI 6.2, Pa
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, mos.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®YACs ®
<br />v Cu Ft,
<br />de above by the proper shipping name, and are classified, packaged, marked and labelled/ rued, and
<br />or a respects in proper condition for transport�ac�co/rding to applicable international and nations veru I regulations"
<br />rintedlryped Name -&4q r�'�"�' S1 natur
<br />Date
<br />4. TRANSPORTER 1 ADDRESS: r__,
<br />Phone 186e)7035-7422
<br />U This is a Through Shipment
<br />St 5 wlR
<br />Applicable Permit Numbers:
<br />SW. Ave
<br />Hauler Rtgr 3400
<br />Fresno,CA 83722
<br />CIE ;
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described
<br />Print/Type Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />N
<br />(-"
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />G. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone 0:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdnt/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />}
<br />8A. DesIgnated Facix:y 88. Akemeh Facility: Sc. Alternate Facility:
<br />8D, Alternate Facility:
<br />5
<br />SterIcy Inc. (Autoclave) ericycle, Inc. (incinerator) SterIcycle, Inc. (Autoclave)
<br />Covante Marlon, Inc
<br />135 WI Swift Ave 10 N. Foxboro Drive 1451 Shelton Dove
<br />WO 151MOMake Road NE
<br />u.
<br />Fresno, CA 9�7, ANNE OFM forth Salt Lake, UT 84054 Hollister, CA 95023
<br />801)936-1171
<br />Brooks, OR 97305
<br />(866)783-742P`a (866)783-7422
<br />(505)393-0890
<br />W
<br />iOST 228/.11-36 TS/OST--83
<br />Permit # 364
<br />FER ®8 2019
<br />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—
<br />received the abov ©� iQ 1astes in accordance with the requirement outlined In that authorization.
<br />Print/Type Name Signature
<br />Date
<br />Transferred containers, c. ft I. Brooks,
<br />
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