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-- MEDICAL WASTE TRACKING FORM NUMBER
<br />s:• tericcle SE OF EMERGENCY CONTACT: CHEMTREC 1.600-424 STANDARD MANIFEST 001 -10 -08 -STD
<br />t:e #: 112 ^ 9 CUSTOMER NO. 12* MDFROO LAV9
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL NEDICAL CENTER
<br />1817 N CALIFORNIA ST
<br />STOCKTON, CA 05204- 8117
<br />(209) 451-9031
<br />11/2812018
<br />11
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<br />CusTowaFt NUMBER 6111862-001 GENERATOR'S REGIeTRATION r
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<br />LI 8C. Amab Facility:
<br />r*ZelginaDad
<br />Ina. Aillo ) Au
<br />2A. DESCRIPTION OF WASTE
<br />20. CONTAINER TYPE
<br />2C, NO, OF
<br />2D, VOLUME
<br />1551 Shelton Drive
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6,2, PGII
<br />TB04 - 28 Gal Tub (Blo) (3.7 cu ft)
<br />CONTAINERS
<br />Cu Ft,
<br />(801)938-1171
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />TB49 - 37 Gal Tub (Blo) (4.9 cu ft)
<br />8/.iA-38
<br />TSIOST-83
<br />6.2, PGiI%
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />14 44Gal Tub(Bio) (5.9 cu ft)
<br />6,2, PGII
<br />Cu Ft.
<br />UN3291,Regulated Medical Waste, n,a.s.,
<br />T821-(�. YTp15)fTY15-()20 Gal Tub(2.7CUFT)
<br />.{�
<br />s
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<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s,
<br />Z
<br />6,2, PGII
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, 1`131134_)AAIP434____)/WC434_,_,.j
<br />Gal Tub(5.7CUFT)
<br />Cu Ft,
<br />1Regulated Medical Waste, n,o.s„
<br />UN32923P
<br />6
<br />KR� - Biosystems Cardboard Box (4.3 Cu 11)
<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 CertItIcation: "I hereby declare that the contents of this consignment are fully and accurately T®TALS ®
<br />R Cu Ft.
<br />delssow above by the proper shipping name, and are classified, packaged, marked and labelled/ lacarded, and
<br />aspects in proper condition for trans rt according to applicable international and nati rnmental regulations"
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<br />Pr ted/Typed Name 1 natur
<br />ai
<br />SPORTER 1 ADDRESS:
<br />Stericycle Inc. C] This is a Through Shipmertt
<br />Phone M:( - 4
<br />Numbers:
<br />4135 W. Swift Ave
<br />Applicable Permit
<br />Hauler Rog# 3400
<br />Fresno,CA 93722
<br />TRANSPORTS RTIF C : Receipt of medical waste as describe
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE MRDLYA 2/ TRANSPORTER 2 ADDRESS:
<br />Phone k:
<br />`11
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pr(nt(Type Name Signature
<br />Date
<br />ro
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />DISCREPANCY INDICATION
<br />17.
<br />11
<br />Fa.dtl
<br />F] 88. ARemato Facility.
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<br />LI 8C. Amab Facility:
<br />r*ZelginaDad
<br />Ina. Aillo ) Au
<br />Steri Inc. (Incinerator) Inc
<br />Sterlcyde, Inc. (Auto T A
<br />4135 W. Swig pate
<br />00 N. Foxboro Drive
<br />1551 Shelton Drive
<br />Fresno, CA 937UU ffiNt: D
<br />' North Sak Lake, UT 84054
<br />Hollister, CA 95023
<br />(858)783-7422
<br />(801)938-1171
<br />(888)783-7422
<br />TSIOST-22
<br />8/.iA-38
<br />TSIOST-83
<br />181). Alternate Facility:
<br />Covanta Marion, Inc Incinerate
<br />4850 Brooklake Road NE
<br />Brooks OR 97305
<br />i50513l�3-0890 .
<br />Permit # 384
<br />NOV 26 20181 1 1
<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 the above indi in accordance with the requirement outlined in that authorization.
<br />C71
<br />Print(Type Name Signature Date
<br />Transferred «, cu A to:, ♦:
<br />Transferred containers,cu ft i.
<br />ORIGINAL
<br />
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