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MEDICAL WASTETRACKING FORM NUM13ER
<br />�.:• ter' Cl °ASE OF EMERGENCY CONTACT. CHEMTREC 14100.42 STANDARD MANIFEST 001 -10 -06 -STD
<br />late : 126 -- 5 CUSTOMER No.2 MDFR00 LFEO
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL. CENTER
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA 952"- 8117
<br />(209) 451-9031
<br />12128f2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR's REGISTRATION 0
<br />2A. DESCRIP71ON OF WASTE
<br />29. CONTAINERTYPE
<br />2C. NO. OF 20. VOLUME
<br />Regulated Medica{ Waste, n.o.s.,
<br />/
<br />TB" _ 28 Gal TUbBio ) (3.7 CU ft)
<br />6,2, PG
<br />6,2, PGII
<br />t
<br />Cu Ft.
<br />UN3291Regulated
<br />Regulated Medical Waste, n.o.s:,
<br />6.2,
<br />TUG - 37 Gal Tub (Bio) (4.9 cu f!)
<br />Cu Ft.
<br />®
<br />6.23PGIi Regulated Medical Waste, n,o.s.,
<br />1 "Gal Tub(6io) (5.9 cu ft)
<br />!
<br />♦ Cu Ft.
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB21-(-)(TPI 5-( )/TY1 b-( )20 Gal Tub(2.7CUFT)
<br />;
<br />W
<br />6.2, PGIICu
<br />Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />IZ
<br />UN362, PGII 91Regulated Medical Waste, n.o.s.,
<br />X34-)/WP43-( )1WWC434 ) Dai TUb`5.7CUFT)
<br />Cu Ft.
<br />Medical Waste, n.o.s.,
<br />6 23PGIj
<br />KR_, - Biosystems Cardboard Box (4.3 CU ft)
<br />Regulated
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.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 Cer0cation: `I hereby declare that the contents of this consignment are fully and accurately TOTALS I
<br />e Cu Ft.
<br />descri boveby the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />s in proper ilio fo transport according to applicable International and nation rnme I regulations"
<br />aDDTRA
<br />Pr ped Name SI nate
<br />w
<br />ORTER 1 ADDRESS:
<br />Ste Inc. ❑ This is a Through Shipment
<br />Swift
<br />Phone #:
<br />Applicable Permit Numbers:
<br />4135 W. Ave
<br />a
<br />Fresno,CA 93722
<br />Hauler Reg# 3400
<br />Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descrl
<br />J �(
<br />t-
<br />y
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />a�
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />h
<br />Applicable Permit Numbers:
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />x
<br />PdnVType Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
<br />�-
<br />Designated Facility: as, Alternate Facility: 8C. Alternate Facllky:
<br />81). Alternate Facility:
<br />J
<br />d, Inc. (Autoclave) S'tsedcyCle, Inc. (Incinerator) SteriCycle, Inc. (Autoclave)
<br />Covants Marion. Inc
<br />a
<br />4135 W, ORM 90 N. Foxboro Orin! 1551 Shobn Ort"
<br />4850 Brooidaks Road NE
<br />LL
<br />.84W
<br />Preens, CAWIM !"Korth SiA I", UT 94491 Honk w, CA SM23
<br />Brooita, OR 97395
<br />f.
<br />{tiGlij7tt�-Y42Y (001)33b-1175 (868)783-7422
<br />{5051393-0890
<br />TS/osT 2Z BtJA-36 TS/OST-83
<br />DEC 2 7 ZOiB
<br />Permit# 364
<br />TREATMENT FA ify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />'
<br />N
<br />received the above indicat wastes in accordance with the requirement outlined in that authorization,
<br />PdnVType Name Signature
<br />Date
<br />Transferred containers, cu ft to : Brooks,
<br />Transferred containers, eu ft to : N. Sall Lake, UT
<br />
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