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C MEDICAL WASTE TRACKING FORM NUMBER
<br />�®O t@rtCj/ci ` Oj EM�I�ENCY CgHTACT: CHEMTREC 1.600-424 STANDARD MANIFEST 001.10 -06 -STD
<br />J CUSTOMER -1
<br />CUSTOMER MDI: ROO LCN3
<br />Transimed atners, cu R 10 : rsrooRS, UK
<br />Transferred containers, cu R to : N. Sak Lake, UT
<br />ORIGiNAL
<br />1. Generator's Name, Address and Telephone Numberj j j Jall
<br />vim
<br />ATTN: 1 11 !1 11 111 li (111 !j!! Ij tj 11
<br />GILL KEDIM CENTER
<br />1617 N CAL FORNIA ST
<br />STOCKTON, CA 952U- 6117
<br />(202),451-9031
<br />12/7/2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />26. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBft – 28 Gal Tub (Blo) (3.7 Wil)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,0
<br />– 37 Gal Tub (Blo) (4.9 cu 2)
<br />6,2, PG11
<br />Cu Ft.
<br />Regulated Medical Waste, n,o.s.,
<br />1 – 44 Gal Tub(Bio) (5.9 cu It)
<br />®
<br />6.N2329 I
<br />4' Cu Ft.
<br />QUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />a
<br />6.2, PGII
<br />Cu Ft.
<br />WUN3291,
<br />Regulated Medical Waste, n.o.s.,
<br />Z
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />43J 34} Gal Tub(51CUFT)
<br />3 -
<br />fi.2, PGII
<br />-- ___,__
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />KR-- – W
<br />6.2, PGI
<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 Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALS ®
<br />t " Cu Ft.
<br />d ed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />re in II respects in proper condition for transport according to applicable international and natio mrn ntal regulations"
<br />I 4h& 40'
<br />12
<br />to
<br />rintedlryped Name natur
<br />—
<br />ANSPORTER 1 D ESS
<br />S I Inc. This IS a 9h Shipment
<br />A
<br />Phone #:
<br />4135 R
<br />W.Hauler
<br />Applicable Permit Numbers:
<br />Req# 3400
<br />< a
<br />Fmn*,CA 93722
<br />a a
<br />TRANSPORTE CEFl ON: Rec(alpt of medical waste as descn
<br />Prini/iype Name Signaturek5��
<br />Date
<br />5. INTERMEDIATE 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/Type Name Signature
<br />Date
<br />ro
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />t
<br />Applicable Permit Numbers:
<br />i
<br />�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z
<br />PrinVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: IIB. Alternate Facility: ❑ 8C. Akemate Facility:
<br />❑ 80. Alternate Facility:
<br />Inc. ( ) SWicycle, he. (Inclnerstor) Stericycle, Inc. (Autoclave)
<br />Covwb Marion, Inc
<br />O
<br />4135 W. VMRAW 90 N, Foxboro Drive 1551 Shobn DT"
<br />4850 l3rooidake Road NE
<br />a
<br />Fresno, CA 937 A.W ORM Nof111 Sat Lake, LIT 94054 Hollister, CA 95023
<br />Brooks, OR 97305
<br />(896)783.7422 (80i),936-1171 (866)783-7422
<br />(505)393-0690
<br />TWOST-22 I.IA-35 'TSIOST 83
<br />07 2010 8
<br />Petmt * 394
<br />_
<br />F
<br />TREATMENT FACILi'tM:� e ' that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />in in that
<br />received the above in a e es accordance with the requirement outlined authorization.
<br />PdnVrypa Name Signature
<br />Date
<br />Transimed atners, cu R 10 : rsrooRS, UK
<br />Transferred containers, cu R to : N. Sak Lake, UT
<br />ORIGiNAL
<br />
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