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a'® � 'I� /C'�' - MEDICAL WASTE TRACKING FORM NUMBER
<br />o ®� CASE CF EMERGENCY CONTACT: CHEMTREC -8 A2 STANDARD MANIFEST 001 -10.06 -STD
<br />.7
<br />p[1I;$ i0Q �#C 126 -- CUSTOMER NO. 21132 MDF' ROO L9TI
<br />Transferred containers, cit ft to : Brooks, OR
<br />Transferred containers, cu ft to : N. Salic Lake, UT
<br />17A
<br />1. Generator's Name, Address and Telephone Number
<br />GILL NED CAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209)451-9031
<br />11/18/2018
<br />CUSTOMER NUmnER 6111852 -ODI GENERATOR'S REGisTRATioN #
<br />2A. DESCRIPTION OFWASTE
<br />213• CONTAINERTYPE
<br />20. NO. OF
<br />20. VOLUME
<br />UN3291 s.,
<br />2PGIRegulated Medical Waste, n.a
<br />TBU _ 28 Gal Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />,{
<br />Cu Ft
<br />6.2. 3PGII Regulated Medical Waste, n.o.s„
<br />TB49 - 37 Gat Tub (8I0) (4,8 cu ft)
<br />Cu Ft
<br />6123291 RagUlatad Medical Waste, n.o,s.,
<br />6.2, PGIi
<br />1 -" Gal Tub(Bio) 5.8 cu ft
<br />( � ( )
<br />©
<br />a Cu Ft.
<br />6232911 Regulated Medical Waste, n.o.s.,
<br />-t`UZI-(, )ffP15-( )f [ Y1S-( 32R Gal Tub(2.7CUFT)
<br />M
<br />Cu Ft.
<br />UJ
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI)
<br />W
<br />Cu Ft.
<br />UN3291
<br />23PGli RagUlatad Medical Waste, n,o,s„
<br />WPI'3-(„—,,,„ )1WP43-(,,,,_)/WC43-L- J Gal Tub(5.7CUFn
<br />--.
<br />Cu Ft.
<br />UN3291 RagUlatad Nodical Waste, n.o.s.,
<br />KR_ - BlosWems Cardboard Box (4.3 cu ft)
<br />Cu Ft.
<br />UN3291 Regulated Madlcal Waste, n.o.s.,
<br />6.2, PGi1
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, PGI)
<br />Cu Ft
<br />3. Generator's Certification: "l hereby declare that the contents of this consignment are fully and accurately T®TALE
<br />/ G Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/ d) and
<br />ar rpspscts jn proper condition for transport according to applicable international and nail on or mental regulations"
<br />Afs
<br />ti
<br />eat)q—
<br />Pr ted/`fypod Name In tura
<br />I ff
<br />M
<br />PORTER 1 ADDRESS:
<br />Sterloyde Inc. This is a Through Shipment
<br />Phone #:t 6O 3-7422
<br />4135 W. wift Ave
<br />S
<br />Applicable Permit Numbers:
<br />d Q
<br />Fresna,CA 93722
<br />Nattier Reg# 34aa
<br />nCL
<br />ZZ
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describ
<br />1 // //{�/
<br />�t�w 4
<br />Print/Type Name3. Signature
<br />Date r/ (.
<br />S. INTERMEDIATE HANDL R /TRANSPORTER 2 ADDRESS: Phone #:
<br />a
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinl/Type Name Signature
<br />Date
<br />M
<br />S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />g
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrtnVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />QA. Designated Facility.- 88. Altornoto Facility: ® 8C. Altarnate Facility: [I so, Alternate Facility:
<br />Ste . Inc. Autoclavedwele, Inc. Incinerate Stericvele, Inc. Atitodave
<br />Covanta hharlon, Inc Incinerate
<br />4135 W, Swi �3EE orm 80 Foxboro Drive 1551 Shetion Drive
<br />4850 Qrooldeke Road NE
<br />Fresno, CAD 722' North Salt Lake, UT 84054 Mobster, CA 95023
<br />Brooks OR 87305
<br />(868)783-7422 (801)936-1171 (866)783-7422
<br />(505)3k-0890
<br />TS/OST-22 NOV 16 2010 3A448/JA-36 TS/OST-83
<br />Permit # 364
<br />W
<br />TREATMENT FACiLthl'�f 1% y that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />t—
<br />received the above Indicatect-ttrastes in accordance with the requirement outlined In that authorfzadon.
<br />PrinYType Name Signature
<br />Date
<br />Transferred containers, cit ft to : Brooks, OR
<br />Transferred containers, cu ft to : N. Salic Lake, UT
<br />17A
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