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<br />OASE OF EMERGENCY CONTACT: CHEMTREC 1.808.42
<br />Route 111: 123 — 17 CUSTOMER NO.2 2
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10 -D6 -STD
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<br />[01€1101?r_u
<br />1. Generator's Name, Address and Telephone Number
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<br />Mil� AS 11 M1 oil
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<br />GILL MEDICAL CENTER
<br />1617 N CAUFORNA ST
<br />STOCKTON, CA 95204- 8117
<br />(202)451-9031
<br />9/18/2018
<br />CUSTOMER NUMarm GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B, CONTAINER TYPE
<br />2C, No, OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6.2, PGII
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<br />fi 23 PGII Regulated Medical Waste, n,o.s„
<br />- 37 Gal Tub 4.9 W)
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<br />1.1143291, Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />- 44 Gal 5.9 CU 9
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<br />6.2, PGII Regulated Medical Waste, n.o.s.,
<br />TW1 15 1 70 GOT 2.7
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<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n,o.s.,
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<br />UN3291, Regulated Medical Waste, n,o.s.,
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<br />UN3291, Regulated Medical Waste, n.c.s„
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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 />described above by the proper shipping name, and are classified, packaged, marked and labelied/piac ed, and
<br />n spects in proper condition for tra ort according to applicable international and natio ental regulatlgns"
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<br />Pri ed/Typed Name "► -c�v� igna ure
<br />4. TR PORTER 1 ADDRESS:
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<br />Phone
<br />X1193 4zz
<br />Applfca le Pe Numbers:
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<br />Ro 3400
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<br />F ,CA 9372:1
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<br />TRANSPORTE TIFICATIO ' ecelpt of medical waste as described o
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<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />aApplicable
<br />Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />PrinUType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Designated Faclltty: 89. Aftemete Facility: 8C. Altemate Facility:
<br />8D. Alternate Facility:
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<br />135 W. &d.Age 1'551 801! »»
<br />4850 Brooidake fad NE
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<br />ii'•iIt10. CA 9372 A14NF OKI L , UT 84054Star, GA 95023
<br />Brooks OR 07305
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<br />868)783-7422 801)938-1171 (888)783-7422
<br />(505)313-0
<br />ST-22 TS/OST-83
<br />Permit 0 364
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<br />REATMENT FACIILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the above indict w Ps in accordance with the requirement outlined in that authorization.
<br />PrinVr-ype Name Signature
<br />Date
<br />Tmwfemw comakws, tau Ill to: Broob, OR
<br />Thmahrred oillittillisMan, eu 2 t : N. Sal LaW, UT
<br />[01€1101?r_u
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