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MEDICAL WASTETRACKING FORM NUMBER
<br />®® ee#eric cle' R SSE ¢F EM tG ENCY INTACT: CHEMTREC 1-800-424- STANDARD MANIFEST 001 -10 -06 -STD
<br />° J # 20 CUSTOMER NO, 21MDFROOL2KO
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: I
<br />11 11 Ij 1J
<br />GILL NVDICAL CENTER
<br />1817 N CALIFORNIA ST
<br />STOCI(TbN, CA 95204- 8117
<br />(209) 451-9031
<br />9/25/201 S
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS
<br />6.2, PGII
<br />TB04 - 28 Gel Tub (Bio) (3.7 to ft)
<br />CU Ft.
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />9 37 Gal Tub {bio} (4.9 CU ft)
<br />Cu Ft.
<br />®
<br />6 23pG11 Regulated Medical waste, n.o.s.,
<br />i GeI Tub(Bia) (5.9 cu ft)
<br />Cu Ft.
<br />U2Regulated Medical Waste, n.o.s.,
<br />1-(___ITP15-(}" t 5-(_'20 Gal Tub(2,7CUFTj
<br />6.2,, PGI PGII
<br />_
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />62, PGII Regulated Medical Waste, n.o.s„
<br />434_..,_)1WC434___j Gal Tub(5.7CUM
<br />Cu Ft.
<br />6 23291PGII Regulated Medical Waste, n.o.s.,
<br />KR_ - Bi arils Cardboard Box (4.3 CU ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGV
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PG[i
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby deciare 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 />respects In proper coon^d�ibo�n for transport according to applicable International and natioMrnmental re Mations"
<br />1
<br />J�
<br />I P ted/Typed Name i Ignature
<br />Date
<br />LU
<br />SPORTER 1 ADDRESS: I
<br />steriolde, Inc. ❑ This is a Through Shipment
<br />Phone M( 60) 7422
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ame
<br />Hauler Regan 3400
<br />Fresno,CA 93722
<br />a a
<br />TRANSPORTER CERTIFICA ON: Receipt f medical waste as descri a
<br />/
<br />tom-
<br />Print/Type Nam Signature
<br />/ ~
<br />Date ___��� L/ �`L
<br />5, INTERMEDIATE HAN ER 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 />Applicable Permit Numbers:
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintfType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Designated Facility: 88. Altemate Facility: SC. Alternate Facility:
<br />E18D. Aftemate Facility:
<br />Ste Inc. Aut a Inc. Incinerate SterivilDle, Inc. Auto
<br />Cmnta Marion, Inc Indnerate
<br />4135 W. S'Yililt Am 0 N. Foxboro Orta 1551 Shekon Orin
<br />4850 Brooldake Road NE
<br />ua.
<br />Fresno, CA 93 Orth Salt Lake, UT 84054 Holister, CA 95023
<br />Brooks OR 97303
<br />(888}783 7422 AtiNEORT1z 801)838-1171 (888)783-7422
<br />t50513d3-0890
<br />TS/OST-22 8/4"s TS/OST-83
<br />Permit 0 384
<br />�
<br />W
<br />SEP 25 2010
<br />o�
<br />TREATMENT FACILITY: I certify that f have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F-
<br />received the above infd Wes in accordance with the requirement outlined in that authorization,
<br />Print/Type Name Signature
<br />Date
<br />Transfe alners, cu Ift to : Brooks, OR
<br />Transferred containers, cu R to : N_ Sal Lake, UT
<br />ORIGINAL
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