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<br />MEDICAL WASTE TRACKING FORM NUMBER
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<br />FER ENCY CONTACT: CHEMTREC 1-800-424- STANDARD MANIFEST tw1.1U-ua-SFU
<br />sEM�� — 7 CUSTOMER NO, 2 MDFROO LK4N
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL NEDICAL CENTER
<br />1817 N CALFORNA ST
<br />STOCKTON, CA 95204- 8117
<br />1111111YWNNIIIIwRI11NEINtlIgq
<br />(209)451-9031
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<br />Tirmfemd r:.:. ,,..y ou A to N. Sak Lake, UT
<br />CUSTOMER NUMBER 6111852-001 GENERATOws RE=TRATmId #
<br />Phone #:
<br />2A. DESCRIPTION OF WASTE
<br />2e• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />_ 2$ Gil 810 3.7 dl >t
<br />CONTAINERS
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />6.2, M11(
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<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />T949 _ 37 Gal Tub (Bio) (4.9 CU A)
<br />Print/Type Name Signature
<br />Date
<br />62, PGII
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<br />7. DISCREPANCY INDICATION
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<br />UN3291 Regulated Medical Waste, n.o,s.,'
<br />, Gal TuNft) (5.9 cu R)
<br />Oeelpna0ed Fa►ctity:
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<br />6.2, PGII
<br />so. Altemate Facility:
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<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />TB21 15{�fTY15-(_�_,_)20 sal ub(2.
<br />480Bt'aonta oarlon, Inc
<br />ldak* Road NE
<br />CC
<br />6.2, PG I I
<br />94 N. FoftM
<br />11661 rIva
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PG I
<br />CA 82722
<br />North Oak La", UT 94054
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<br />6 23PGII 91 Regulated Medical Waste, n.o.s„
<br />34!) 43{--J/WC43-(__) Gal TUb(5.7CUM
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<br />(866)783F-7422
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KR - Biosystems Cariftioard Box (4.3 cu iia
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<br />UN3291, Regulated Medical Waste, mos.,
<br />Permit# 364
<br />P11
<br />6.2, PGI!
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI)
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<br />3. or's CerWicadon: "I hereby declare that the contents of this consignment are fully and accurately T®TA LS ®
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/ ad, and
<br />respects in proper cond' r transport according to applicable international and natio rnme tal regulations"
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<br />PI)ad1Tped Name v `- v SI natur
<br />atB
<br />4. T PORTER 1 ADDRESS:
<br />❑ Thmoh Shipment
<br />Phone #A$8 3-7422
<br />Sterkyde Inc. This Is a
<br />4135 A
<br />Applicable Permit Numbers:
<br />HauW Rog# 3400
<br />R
<br />Fresna,t,A 93722
<br />TRANSPORTER CERTIFICA N: Recei t of medical waste as descri
<br />Print/Type Name Signature
<br />Date
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<br />Tirmfemd r:.:. ,,..y ou A to N. Sak Lake, UT
<br />3 INTERMEDIAT AN R 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />I
<br />7. DISCREPANCY INDICATION
<br />Oeelpna0ed Fa►ctity:
<br />as. Alternate Facility:
<br />aC. Altemate Facility:
<br />so. Altemate Facility:
<br />1
<br />ktC. _
<br />D(Incinerator)
<br />}
<br />Shelton Inc.
<br />480Bt'aonta oarlon, Inc
<br />ldak* Road NE
<br />4195
<br />94 N. FoftM
<br />11661 rIva
<br />'aFresno,
<br />U.tSat
<br />CA 82722
<br />North Oak La", UT 94054
<br />HoMlsiar, CA 65023
<br />Brooks, On 97305
<br />POV1 2-22 �g ®� ��
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<br />(80i)23ei m
<br />(866)783F-7422
<br />(505393-0894
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<br />TS/OST-83
<br />Permit# 364
<br />P11
<br />TREATMENT FACILITY: I cert'Ity that 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 authorization.
<br />Print/Type Name Signature
<br />Date
<br />w, dillOrt, ---=— CU ft to Bmka, 1
<br />Tirmfemd r:.:. ,,..y ou A to N. Sak Lake, UT
<br />
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