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MEDICAL WASTE TRACKING FORM NUMBER
<br />*i ®� eI�ICCIP® A5E qF EMERGENCY CONTACT: GHEMTREC t 80g 424 STANDARD MANIFESTooS-to-06-StD
<br />to #: 123 - 4 CUSTOMER NO, 21 MDFROOL3I L
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATN: Fill 11111111lil
<br />1111
<br />1� ! 11i 111 III i
<br />ME
<br />GILL NEDIGAL. CENTER
<br />1017 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 0117
<br />(209) 451-9031
<br />10/212018
<br />CUSTOMER IJUM19ER 811185 2- 001 GENERArows REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C, NO. OF
<br />2D. VOLUME
<br />6 23291, Regulated Medical Waste, n.o.s.,
<br />+� _ 28 Gil Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />6 2, P91i Regulated Medical Waste,
<br />TB49 _ 37 Gil Tub (Bio) (4.9 cu ft)
<br />Cu Ft.
<br />®
<br />UN3PGII Regulated Medical Waste, n.o,s.,
<br />1 -,i.4 Gal Tub(131o) (5.9 cu ft)
<br />Cu Ft.
<br />Q
<br />UN3291 Regulated Medical Waste,n.o.s.,
<br />TB21-(- )20 GalTub(2.7CUFT)
<br />M
<br />6.2, PGII
<br />_)/TR15-(.,,.._,_}iTY15-(
<br />Cu F1.
<br />W
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />Lu
<br />6.2, PGII
<br />Cu Ft.
<br />Regulated Medical Waste, .o.s„
<br />6 2 PGII n
<br />34_ /WP43-(_,_,_„)1WC43-(___,,j Gal Tub(5.7GUFT)
<br />,
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />KR Biosystems Cardboard Box (4.3 cu It)
<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, 13131i
<br />Cu Ft.
<br />3. Generator's Cartlficetion: "I hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labeiled/placarded, and
<br />aspects in proper conditi n for transport according appl�ble into national and natio nmenial regui 1
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<br />rinted/Typed Name e� f n tune
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<br />4. T NSPORTER 1 ADD
<br />Stelicycie, Inc. ❑ This is a T rough Shipment
<br />Phone II($1 -7 .22
<br />Applicable Permit Numbers:
<br />4135 W. Swift Aue
<br />Hauler RegrlR 3400
<br />M a.
<br />Fresno,CA 93722
<br />off. C
<br />TRANSPORTS ERTIFI /Nifi�,d.0 Aeceipt o adical waste as descri
<br />r
<br />~
<br />Print/Type Name Signature
<br />Date
<br />'
<br />5. INTERMEDIATE ANDL R 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />N
<br />W
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medficai waste as described above.
<br />Pdnt/rype Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />,c �
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />RX
<br />—
<br />F
<br />Print/Type Name Signature
<br />Date
<br />7. DIS EPANCY INDICATION
<br />8A. Designated Facility: Attemate Facility: 8C. Alternate Facility: ❑ SD. Alternate Facility:
<br />J
<br />Stela inc. Auto yde, Inc. Incinerate Sterimsek, Inc. Autoclave
<br />Covanta Nation. inc Incinerate
<br />U
<br />JOIN.
<br />4135 W. Swift A e Foxboro Drive 1551 Shelton Drive
<br />4850 Brooktake Road NE
<br />r*esna, 0^"722 Deft Laker, UT t34W viol mar, CASS029
<br />Brooks OR 97305
<br />F
<br />(8a(F)73374zz 3 0-1171 $0gWTSS/OST-22 DALF-O NE -0R- 8/JA-36 TS/OST-83 2Z
<br />t50513I�3-bS9D
<br />Permit 364
<br />(}{'T (�
<br />TREATMENT FaCI[ 4 Pb kat 1 have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />H
<br />received the above InMeated wastes In accordance with the requirement outlined in that authorization.
<br />Q.44,4&
<br />Printrrype Name a Signature
<br />Date
<br />tx! ers, cu R to: Brooks. UK
<br />Transferred containers, cu It to ; N. Salt Lake, UT
<br />ORIGINAL
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