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MEDICAL WASTE TRACKING FORM NUMBER
<br />!i®® teric dee SF�fFs GENCY A IDNTACT:CHEMTREC180042 MDU�AR� M�+ F Ti t-fo-o6•STO
<br />CUSTOMER NO. 32 tJ ,?F�J
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />II
<br />GILL MEDICAL. CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031
<br />10/16/2018
<br />CusTOMER NumeER `/� JL�VI/� GENERATOR'S REO(sTRATION M
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />URegulated Medical Waste, n,o.s.,
<br />TIM — 28 Gal Tub (Bio) (3.7 Cu R)
<br />CONTAINERS
<br />6.22,, Poll
<br />PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB49 „ 37 Gal Tub (Blo) (4.9 cu 1t)
<br />6.2, Poll
<br />Cu Ft.
<br />I=
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T814 — 44 Gal Tub(Blfa (5 9 GU }�
<br />0
<br />6.2, PGII
<br />t
<br />Cu Ft.
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB214 Gal Tub(2,7CUFT)
<br />W
<br />6.2, PGII
<br />__r_YMI5-(—JliY15-(—)20
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />W
<br />6.2, PGII
<br />Cu Ft,
<br />0
<br />6 2, Poll Regulated Medical Waste, n.o.s„
<br />1rYB43-(--YM43{--J/WC434--j Qat Tub(5.7CUFT)
<br />Cu Ft.
<br />623Paii Regulated Medical Waste, n.b.s.,
<br />J(R Y Dios ems Codboatnd Boit (4.3 cu 4)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s„
<br />6.2, PGII
<br />AZOU.',
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6,2, PGII I
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately �O—T'L$ ®
<br />Cu Ft.
<br />described above by the proper shlpping name, and are classified, packaged, marked and labeiled/placarded, and
<br />are in all respects In proper condition for transport according to applicable international and national governme regulations
<br />Printed/iyped Name V ' �� Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericyok Ine. ElThis is a Through Shipment
<br />Phone —
<br />4135 W. 'AIR Arne
<br />Applicable Permit Numbers:
<br />2 2.
<br />Fresno,CA 83722
<br />Hauler Re 3400
<br />a a
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />H
<br />�
<br />Print/Type Name (gnature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone 1}:
<br />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 />'w
<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 />Pdnt/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />BA. Designated Facility: 88. Alternate Faciltty: F] 8C. Altemate Facility:
<br />BD. Aitemate Facility:
<br />eri Inc. Auto arl , Inc. Incinerate Steri , Inc. Auto
<br />Covanta Marion, Ina Incinerate
<br />lu
<br />135 W, Swig 0 N. Foxboro Drive 1551 Shekon Drive
<br />4850 Brookiake Road NE
<br />resno, CA 93722 Orth Sall Lake, UT 84054. Holster, CA 95023
<br />Brooks OR 97305
<br />t
<br />868}783-7422 801}936-1171 (868)783-7422
<br />(506)33-0890
<br />TS/0 ST -22 8/4436 TS/OST-83
<br />Permit r8 364
<br />i—
<br />Pt
<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 />t—
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Pdnt/Type Name Signature
<br />Dale
<br />cans erred containers, cru R to ; roe
<br />Transferred containers, cu R to : N. Salt Lake, UT
<br />
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