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MEDICAL WASTE TRACKING FORM NUMBER
<br />Cee Steric clew#ASE OF EMERGENCY CONTACT: CHEMTREC 1-$00 424 STANDARD MANIFEST DOI-10-WSTD
<br />#: 123 _ 4 CUSTOMER NO. 2 MDF'ROOL7A6
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number amI
<br />ATTN:
<br />GILL NEDiCAL CENTER
<br />1817 N CALIFORNIAST
<br />STOCKTON, CA 05204- 8117
<br />(209)451-9031 10/30/2018
<br />CUSTOMER NUMBER 18111862-001 GEN£RATOR'e REQtaTAmm �
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO, OF 20, VOLUME
<br />6 2, PGIRegulated Medical Waste, n.o.s.,
<br />I
<br />— 28 Gal Tub Blo 3.7 cu ft
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291
<br />6 PGIIRegulated Medical Waste, n.o.s.,
<br />- 37 Gil Tub (Blo) (4.9 cit ft)
<br />,
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o,s,,
<br />6.2, PGII
<br />61.4;44 Gill Tub(Bio) (5. Cu ft)
<br />0
<br />Cu Ft.
<br />QUN3291
<br />Regulated Medical Waste, n.o.s.,
<br />fi.2, PGII
<br />TB21 15 15 20 QAI Tub 2.7CU
<br />1--! °' FT)
<br />Cu Ft,
<br />W
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />W
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />43 3 tial Tu 5.7CU
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KR — BkaWernis Cardboard Box 4.3 cy ft
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PG [I
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />CU F.
<br />3. Generstor's Certification:'I hereby declare that the contents of this consignment are fully and accurately TOTALS ® v Cu Ft.
<br />de above by the proper shipping name, and are claseNied, packaged, marked and labelled/placarded. and
<br />In aspects in proper condition for transport according to applicable international and nail nme r latlons"
<br />I i
<br />i rt%'
<br />I nted(ryped Name i& SII Data
<br />NSPORTER 1 ADDRESS: Phone 1f'888} 3-7422
<br />Steri Inc. This
<br />iS a ThroUgh Shipment Appllcab a Permit Numbers:
<br />C R
<br />Fre3> CA 93722 Hau r Ra 3400
<br />CL
<br />TRANSPORTS CERTIFI : RecelpL&Wedlcal waste as described a ve. f
<br />Print/Type Nlam'��aj Signature Date `
<br />6. INTERMEDIATE /TRANSPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />o,
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />T. DISCREPANCY INDICATION
<br />GA. Deftnated Facility: Facility: 8C, Attemate Facility: ED. Aftemate FacifFty:
<br />f
<br />Ste Ine. AW , Inc. M e Sterivide, Inc. o Counta Marion, Inc Indneralis
<br />a
<br />t86AaM
<br />4135 W. rc Drive 1551 eton 4850 Brooklalke Road NE
<br />NEONLake.
<br />Priat:na, QA UT 84054 er. CA 85023 Brooks OR 97305
<br />Lu
<br />(866)7837422 (505}36-0890
<br />112 °►-3e
<br />TSIOST-89 Permit # 364
<br />OCT 3 0 2016
<br />TREATMENT FAGI2,1 ratify that I have been authorized by the applicable state agency to accept untreated medicat wastes and that I have
<br />t—
<br />received the abovecaledwastes In accordance with the requirement outlined in that authorization,
<br />Pdnt/Type Name Signature Date
<br />TrAnSilliffed contairwro. wftto_Broob,OR
<br />Transferred conlainlem, au IIt to :N. Salt Lab, UT
<br />ORIGINAL
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