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e } /� �+MEDICAL WASTE TRACKING FORM NUMBER
<br />ii® ` iicycle OF EMERGENCY CONTACT: CHEMTREC 14=42 STANDARD MANIFEST 001 -10.06 -STD
<br />+ WASE
<br />e #. 126 — 15 CUSTOMER NO.2 ME)FROO LGC9
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILT. MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95241- 6117
<br />(209) 451-9031
<br />1/4/2019
<br />CUSTOMER NUMBER 6111852-001 GENEftAmR's REWsTRATWN #
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, mo,s.,CONTAINERS
<br />6.2, PGlf
<br />iB04 — 28 Gal Tub (BID) (3.7 Cti ft)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TWO _ 37 Gal Tub (BID) (4.9 cu ft)
<br />6.2, PGI
<br />Cu Ft.
<br />IE
<br />8 232P9C�1i, Regulated Medical Waste, n.o.s.,
<br />1 _ Gal Tub(Blo) (5.9 cu lilt)
<br />Cu Ft.
<br />6 23291PGIRegulated Medicai Waste, n.o.s.,
<br />TB2'14-- f PI54—)rI•Y15,(, „„,,,,)20 Gal Tub(2.7CUFT)
<br />%
<br />!
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />fi 2, PG Regulated Medical Waste, n,as.,
<br />WB434)/WP43 43 Gal Tub 5.7CUFT
<br />'(�/WC"(� ( )
<br />Cu Ft.
<br />Regulated Medical Waste, n,o.s„
<br />6.2, PGIj
<br />KR - Biosystems Cardboard Box (4.3 Cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.c.s.,
<br />6.2, PGiI
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's CertNtcatlon: "I hereby declare that the contents of this consignment are fully and accurately T®TALS III -
<br />Cu Ft.
<br />descdbed above by the proper shipping name, and are classified, packaged, marked and labellecUplacarded, and
<br />a respells in proper io far transport acccrding to applicable international and natio rnmentallrrjegulations°
<br />r to
<br />Pr tedi ryped Name Signa ure "
<br />4. TRA PORTER i ADDRESS:
<br />Sterloycle, Inc. ❑ TRIS Shipment
<br />Phone #:($66)7$3-7422
<br />Is 8rough
<br />Applicable Permit Numbers:
<br />4135 W. Swift Atre
<br />Hauler Regal 3400
<br />Q
<br />N
<br />Fresno,CA 93722
<br />CL a
<br />oe
<br />TRANSPORTER CERTIFI . ON: Receipt of medical waste as describ
<br />j
<br />~Pdnt/Type
<br />Name Signature
<br />Date
<br />S. INTERMEDIAT N 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 />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrInUType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Designated FaclIty: 8B. Alhmatt Fecltity: SIC. Alternate Facility;
<br />BD. Akemate Facility:
<br />Stericycle, Inc. (Autoclave) S dcycle, Inc. (Incinerator) Stericycle, Inc. (Autoclave)
<br />Cwanta Marion, Inc
<br />4
<br />4135 W, NEOMU 90 N, FQAoM DrIVIII 1561 Sh4bn DrNe
<br />4860 BrooKlake Road NE
<br />LL
<br />Ch
<br />l:reeartn, )` o tt+ Calk Lake, Lrr 841361 Holtli&W, CA 95023
<br />Brooks, OR 97305
<br />itlsd)7tf -7422 (501)921& -mi -(8158)783-7422
<br />(;106)393-338�p
<br />S/OST22JAN ® 4 2029 3A -448/,1A-38 TSIOST 83
<br />TS/OST-22 JAN
<br />Permit # 364
<br />W
<br />TREATMENT F •certify that I have been authorized by the applicable state agency to wept untreated medical wastes and that I have
<br />F
<br />received the above indiciWwastes in accordance with the requirement outlined in that authorization.
<br />Printtrype Name Signature
<br />Date
<br />I F551 rafted contaffiers, sill ft to : Brooks,
<br />Transferred containers, cu ft to : N. Sak Lake, LIT
<br />
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