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<br />r S* MEDICAL WASTE TRACKING FORMN
<br />UM6ER
<br />terecyck*eEgl� EMERGENCY CONTACT: CHEMTREC 1-Bo}424 STANDARD MANIFESI WI -W -M -SID
<br />S_ 22 CUSTOMER NO. 201 ^
<br />MDI~ ROO bJ6R
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />jI
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-90311
<br />1/25/2019
<br />QsTomm Numam 6111862-001 GENERATOR'S R9042' RATION M
<br />2A. DESCRIPTION OF WASTE
<br />2e. CONTAINER TYPE
<br />2C. NO. OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s„CONTAINERS
<br />T004 - 28 Gal Tub (Sic) (3.7 Cu ft)
<br />6.21 nil
<br />Cu Ft.
<br />23P2G1i1 Regulated Medical Waste, n.o.s.,
<br />6.2.
<br />TB49 - 37 Gill Tub (Bic) (4.9 cu ft)
<br />Cu Ft.
<br />CC
<br />623PGI) Regulated Medical Waste, n.o.s.,
<br />1 _ 44 Gal Tub(Blo) (55.9 ill ff)
<br />R Cu Ft.
<br />F
<br />Regulated Medical Waste,n.o.s.,
<br />T821-(-)fTPI5-(-)/TY15I-(_,,,,____,)20GalTub(2.7CUFT)CC
<br />623PGI(
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />6.2, PGI(
<br />W
<br />Cu Ft.
<br />23PGIj Regulated Medical Waste, n.o.s.,
<br />yM43-( )/WP43-(__JMIC43-(______) tial Tub(5.7CUFT)
<br />Cu Ft.
<br />fi 2, PGI(Regulated Medical Waste, n.o.s.,
<br />KR - Bios)rstems Cardboard Box (4.3 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />62, PGIi
<br />Cu Ft.
<br />UN329i, Regulated Medical Waste, n.o.s.,
<br />62, PGIi
<br />CuFt.
<br />3. Gemretor's Certification: `I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placard—, and
<br />a respects In proper corAtion for transport according to applicable International and net rnme t ulations
<br />i rintedlT Namei n ure
<br />at
<br />. TPANSPORTER t ADDRESS-
<br />Sterlcyde, Inc. [ This is a ough Shipment
<br />Phone488OPM-7422
<br />Applicable Permit Numbers:
<br />4136 W. Swift Age
<br />a
<br />Fresno,CA 83722
<br />Hauler Rem 3400
<br />4C 0
<br />Ic Z
<br />TRANSPORTER CERTIFICATIO : Recut of medical waste as descd
<br />Print/Type Name Signature
<br />Date
<br />,.
<br />S. INTERMEDIATE H 1- !TRANSPORTER 2 ADDRESS:
<br />Phone #: .
<br />a�
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print[Type Name Signature
<br />Date
<br />6. 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 />PrinttType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />W. Facinty: 8C. Altanaata Faculty:
<br />So. Akornate Faallity:
<br />Ste. (AutaGlave) rlcycle, lnG. (Incinerator)Staricycle, Inc. (Autoclave)
<br />�!IAV4
<br />Covents Marton, Inc
<br />4135 0 N. F4xp¢n4 arlvre 1551 8h'61ton ON*
<br />4850 81`001W goad NE
<br />LL
<br />Fraena, e A e'722 Zwlk La", UT WAM "r Attst:et•, CN 95028
<br />13toriks, OR 911305
<br />(tIbt;jYtIS-742Y 171 (1!16115)783..7422
<br />TS/OST 22 3M948/JA-36
<br />M5)393-0890
<br />TS/OST-83
<br />Permit * 364
<br />TREATMEN ff��IITT,,YY''%% ity that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />the In the In that
<br />received e'IAificAt wastes accordance with requirement outlined authorization.
<br />00
<br />Pdnt/Type Name Signature
<br />Date
<br />containers, CU ft to : Brooks,
<br />Transferred containers, cu R to : N. Salt Lake, UT
<br />
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