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MEDICAL WASTE TRACKING FORM NUMBER
<br />®® Steric de` ASE QF E(dF,RQENCY �CNTACT; CHEMTREC 1-800424- STANDARD MANIFEST Wt -IU -0"I V
<br />J t6 1� 11b l CUSTOMER NO.211 M)r%FROO LI 9H
<br />1. Generator's Name, Address and Telephone Number'01111,011111111
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<br />ATTN:
<br />i( i1 jE
<br />G ILL IVEDICAL CENTER
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 8117
<br />(209) 451-9031
<br />1/1812019
<br />CUSTOMER NUMBER $111852-001 GENERATOR's ftaur RATm M
<br />2A. DESCRIPTION OF WASTE
<br />213, CONTAINERTYPE
<br />2C. NO, OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />�Q,� _ 28 GaI Ttlb //i3I0 //3,7 cu )
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<br />CONTAINERS
<br />6.2, PGIi
<br />1 t
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />9.37 Gal Tub (Bio) (4.9 cu ft)
<br />6,2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medial waste, n.o.s.,
<br />14 - Gal Tub(Blo) (5.9 cu R)
<br />6.2, PGII
<br />c Cu Ft.
<br />FF
<br />F
<br />Q
<br />62311 Regulated Medical Waste, n.o.s.,
<br />TB71.(�15-L,r , 1 -L �, W
<br />cc
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />IZ
<br />91 Regulated Medica[ Waste, n.o,s.,
<br />34 )/WP434_____)/WC43-( ) Gal Tub(5.7CUFT)
<br />6.2, PGII
<br />...
<br />Cu Ft.
<br />Medical Waste, n.o.s.,
<br />231
<br />KR— . Biosystems Cardboard Box (4.3 cu R)
<br />6 1 Regulated
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.a.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />U N3291 Regulated Medica! Waste, n.o.s.,
<br />6.2, PGII
<br />Cy Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TAL.S ®
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelted/piacarded, and
<br />are in all respects In proper condition for transportaccording to applicable International and national governme gulations"
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<br />/
<br />Print ed/T Name (mss t s-� Signature
<br />Date
<br />4. TRANSPORTER 1,ADpRESS:
<br />Stent y Ile Inc. a Throu h Shi Balt
<br />Swift
<br />Phone #4866)783-7422
<br />Applicable Permit Numbers:
<br />4 5 W.
<br />Hauler Reg# 3400
<br />4This,
<br />ti1lo2
<br />TRANSPO FI ATIt f ill waste as des
<br />PrinVTWm Nam Signature
<br />Date
<br />5. INTERMEDIA HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone :
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/iype Name Signature
<br />Date
<br />n
<br />a. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone f►;
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Print/iype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />�-
<br />Ignated Facility: 88. Alternate Facility: 5C. AUrrwta Facility:
<br />so. Alfemata Facility:
<br />J;964aybo,
<br />Inc. (Autoctave) Stericycle, Inc. (Incinerator) Stericycle, Inc. (Autoclave)
<br />Coventa Marion, Inc
<br />"
<br />4135 W. SWIR AV* 90 N. Foxboro DWS 1551 Shobn Drl"
<br />4950 Brooklako Road NE
<br />parww, CA 02722 Math OdtLA", UT 2401M Ho"ar, CA f91T;t]23
<br />Brook&, OR 97303
<br />j
<br />(tststM33-7472 (50t)235-1171 (866)78-,47422
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<br />T 2
<br />TSIOS2 3A-448/JA-36 83
<br />Permit # 3154
<br />IIITSMT
<br />cc
<br />DAL£ ANN£ 01`912
<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 />received thOWell0ld. wastes In accordance with the requirement outlined In that authorization.
<br />Print(iype Name Signature
<br />Date
<br />;. �, .•Rc cu it to . roo ii,
<br />`� Tradsfelred containers, cu R to : N. Salt Lake, UT
<br />
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