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MEDICAL WASTE TRACKING FORM NUMBER
<br />0.-*.* 'ter'icyde® ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424 STANDARD MANIFEST 001 -10.06 -STD
<br />icy
<br />ute #: 126 — 6 CUSTOMERNO.2 MDFROOLBU9
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204-6117
<br />(209) 451-9031
<br />11/9/2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2®• CONTAINERTYPE
<br />2C. NO. OF
<br />2D, VOLUME
<br />UN3291 Regulated Medical Waste, n•o•s.,
<br />6.2, PGIi
<br />T804 - 28 Gal Tub (Bio) (3.7 ecu 1t)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGI)
<br />37 Gal aUa t.CU it
<br />(Si
<br />T849 ( ) t49 )
<br />o) ! T
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />Bi GU
<br />Tub(Bio) (5ft)
<br />G b! T
<br />4 TB1_, Gal
<br />Q
<br />6.2, PGII
<br />.9 ,
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB21-(_)fj '15-4 )f1'Y154 )20 Gal Tub(2.7CUFT)
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291Regulated 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, PGII
<br />WB43-( )A1VP43-( )/WC43-(____ J Gal Tub(5.7CUFT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />KR - BiosWems Cardboard Box (4.3 Cu ft)
<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 />Cy Ft.
<br />3. Generator's Certification: "i hereby declare that the contents of this consignment are fully and aocurately TOTALS®
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects In proper condition for transport according to applicable international and national governmental regulations"
<br />X Printed(Typed Name Signature
<br />4.TRANSPORTER 1 ADDRESS:
<br />❑ Through Shipment
<br />Date
<br />Phone #:(866)783-7422
<br />Stericycle, Inc. This Is a
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
<br />Xresno,CA
<br />93722
<br />ME
<br />Z
<br />TRANSPORTE ERTIFICAT N: Receipt of medical waste as described a ve,
<br />�`
<br />rJ
<br />li 18
<br />PrinUType Name Signature
<br />Date
<br />5. INTERMEDIATE NDLER 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 />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />aApplicable
<br />CERTIFICATION:
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER Receipt of medical waste as described above.
<br />a
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />SA. DeelgnaW Facility: 86. Alternate Facility: ❑ 8C, Alternate Facility:
<br />SD, Alternate Facility:
<br />Stericyde, Inc. AutocWm Sterlwele, Inc. Incinerate Stericyde, inc. Autodave
<br />Covanta Marion, Inc incinerate
<br />4
<br />4135 W. Swift Ave 90 N. Foxboro Drive 1551 Shelton Drive
<br />4850 Brooklake Road NE
<br />a
<br />f"reana, CA►93722 North Sail Lake, UT 84064 Hollister, CA►95023
<br />Brooks OR 97305
<br />(886)783-7 �& ANNF. ORTIZ (801)938-1111 (866)783-7422
<br />(505)343-0890
<br />Z
<br />TS/OST-2 8/JA-36 TS/OST-83
<br />Permit * 364
<br />pit
<br />TREATMENT FACiLt' TY: that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />FAC"
<br />F
<br />received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />14
<br />Print/Type Name Signature
<br />Date
<br />Transforred containers, cu 8 to : Brooks, OR
<br />Transferred contalfrim, cu It to : N. Salt Lake, UT
<br />ORIGINAL
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