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<br />re o EM�ERG�ENCY CONTACT: CHEMTREC 1-800-42
<br />CUSTOMER NO! 2 2
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10.06 -STD
<br />MD)iROOLDL4
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: 11 11
<br />111111111 N I 1111111111111
<br />GILL hiEDiCAL CENTER
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 8117
<br />(209) 451-9031
<br />12/14/2018
<br />�g A�!y�
<br />CUSTOMER NUMBER Q1 1 i 85.E -0V7 GENERATOR'S REWMATION If
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />2C. NO. OF
<br />2D, VOLUME
<br />Regulated M
<br />6.22,,PGIedical Waste, n.o.s.,
<br />UN3291 PGI I
<br />T`804 _ 28 Gal Tub (Bio) (3.7 eu R)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />- 37 Gal Tub Bio . dl
<br />(Bic) (�)
<br />Cu Ft.
<br />CC
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />1 - 44 Gal Tub(Bio) (5.9 cu 11l)
<br />, Cu Ft.
<br />6 23PGII Regulated Medical Waste, n.o.s,,-TB21-(.__,
<br />)ITP15-{._,_„}ITY1 S-(_.�,.,_ )20 Gal Tub(2.7CUFTj
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />W
<br />Cu Ft.
<br />6
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />W8434 )/WC43-( ) Gat Tub(5.7CUFT)
<br />--)NVP434--
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KR - Bios'Wems Cardboard BOX (4.3 cu 1t)
<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 />Qu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALS ®
<br />Cu Ft
<br />de above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />II spects In proper condition for transport according to applicable international and natl gov ment regulati ns °
<br />1 VYe
<br />jj (
<br />P nted/Typed Name i Pure
<br />CC
<br />4. NSPORTER 1 ADDRESS;
<br />Sterleyde Inc. This is a Through Shipment
<br />Phone #:(30ti)783-7422
<br />Applicable
<br />4135 W. i6 itt Ave
<br />Permit Numbers:
<br />a
<br />Fresno,CA 83722
<br />Flamer Reg# 3400
<br />aZ
<br />TRANSPORTS ERTIFiC N: Receipt of medical waste as described
<br />(LrF tr�
<br />PdnMpe Name Signature
<br />Date
<br />5. INTERMEDIATE HAND ER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />NW
<br />F-
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />'
<br />Printrrype Name Signature
<br />Date
<br />8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #;
<br />llCC
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z s
<br />—
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Zrigneeed Facility: El 8e. Alternate Facility: El 8C. Akamate Facility:
<br />BD. Afbmato Facility:
<br />Icycle, ( Stericycie, Inc. (Incinerator) Stericycle, Inc. (Autoclave)
<br />Covanta Marton, Inc
<br />a
<br />4185 W, 90 N, F*xboro Od" 1651 Shobn Drl"
<br />4850 ftoklak4 Road NE
<br />eL
<br />Fresno, CA 93722 North Salt Lake, UT 84054 Hollister, CA 95023
<br />Brooks, OR 97305
<br />LU
<br />(866)763- 018 (801)§36-1171 (866)783-7422
<br />TMST -2 3"80A-38 TS/OST-83
<br />(505)393-0830
<br />Permit * 364
<br />ILU
<br />TREATMENT F iL FAc`ertify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F-
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/type Name Signature
<br />Date
<br />Transferredcontainers, cu tt to : Brooks, OR
<br />Transferred containers, cu 8 to - N. Sat Laka, UT
<br />
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