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MEDICAL WASTE TRACKING FORM NUMBER
<br />•® ®1! Stericyde® ASE OF EMERGENCY CONTACT: CHEMTREC 1-SDO-4
<br />--NO,
<br />2 STANDARD MANIFEST 001 -10 -06 -SIU
<br />J Route 0: 123 20 CUSTOMER NO.21 2 MDFROO L4 GP
<br />1. Generator's Name, Address and Telephone NumberI
<br />TTN:
<br />�
<br />11111 BOB
<br />GILL MEDICAL CENMR
<br />1617 N CALFORNIA ST
<br />STOCKTON, CA 05204- 6117
<br />(209) 451-2031
<br />1®1912018
<br />CUSTOMER Nu1A6ER 6111 852 GENERAMR•s REGISTRATION N
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.as.,_
<br />6.2, P(311
<br />,�8 G� (ft) (3.7 cu A)
<br />TIM i
<br />CONTAINERS
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<br />UN3291, Regulated Medical Waste, n.a.s.,
<br />6.2, PGII
<br />. 37 Gal Tub (Bio) (4.9 cu 1t)
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<br />®UN3291
<br />Regulated Medical Waste, n•o•s•,
<br />ITO- 44 Gal Tub(Bio) (5.9 til III)Cu
<br />6.2, PGII
<br />Ft.
<br />4
<br />UN3291 Regulated Medical Waste, mos.,T�21
<br />15•�l� � ' 154 )2Q i TW(2.70M
<br />6.2, PGII
<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 />a
<br />UN3291 Regulated Medical Waste, n•o.s.,
<br />6.2, PGII
<br />34434---MC434--, (384 TUX5.7CUM
<br />Cu Ft.
<br />62, PGII 91 Regulated Medical Waste, n,o.s,,
<br />KR— - BiOrMeMs Cardboard Box (4.3 cu il)
<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
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<br />3, Generator's Certification, "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
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<br />de above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />re . spects in proper condition for transport aa:ording1to{jap�plicabblle Innternrtional and na omenta egu tions"
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<br />t Fri1 Name °- " "� Signaiure
<br />Date a
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<br />PORTER I ADDRESS:
<br />Stedcycb Inc. This Is a Through Shipmmnt
<br />Phone "88) 422
<br />Applicable Permit Numbers:
<br />Fc
<br />4136 W. Sr1wI
<br />Hauler Roo 3400
<br />Mo.
<br />Fresno,CA 03722
<br />a
<br />TRANSPORTER CERTIF CA O - Receipt of medical waste as descri
<br />—15;PrtnUType Name Signature
<br />Date
<br />S. INTERMEDIAT ND 2 ]TRANSPORTER 2 DRESS:
<br />Phone N:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printfrype Name Signature
<br />Date
<br />s
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />Permit Numbers:
<br />4 cc
<br />5
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable
<br />a
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />M. Doslgnatad Facility: 8B. Alternate Facility: ❑8C. Atomate Facility:
<br />SD. Atemme Facility:
<br />o Inc. , Inc. kndm Sto ALd
<br />Inc Indnerattm
<br />Covanta Maron.
<br />a
<br />RW.
<br />135 W. oxboro 1551 on Drive
<br />4850 Srooklake Road NE
<br />MOM, CA 0 $ot -t 171 Luke, UT ar, CA 85023
<br />�t�nr�ylr QRTI�(800)783-7422
<br />83
<br />®rtaotcs OR 87305
<br />1545331390
<br />w
<br />TSIOST-22 JA416 TWOST-83
<br />Permit # 364
<br />Pit
<br />OCT 09 MO
<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 />h
<br />received the above.r&IIcated?wastes In accordance with the requirement outlined In that authorization.
<br />rte"
<br />Prini/iype Name Signature
<br />Date
<br />. cu IN to ; Broom. OIR
<br />Tiniiiiiled contalners, cu It to ; N. Sak Laim, UT
<br />
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