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ER N0.MEDICAL WASTE TRACKING FORM N
<br />UMBER
<br />*t%EF:EEg�TACT:CHEMREC42 STANDARD MANIFEST 10-6-STDG®ia® terIC Cj 2CUSTOMMDLOOL���
<br />+r : ►Jill
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: 1111 11 1i (1t
<br />11 II
<br />GILL WDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204.6117
<br />(209)+451-9031
<br />9/11/2615
<br />'
<br />CUSTOMER NUMBER H * R^""�+ GENERATOR'S REGAsTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE
<br />20. NO. OF
<br />2D, VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />71304 - 28 Gat Tub (Bio) (3.7 CU ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft,
<br />UN3291, Regulated Medical Waste, n.o.s,,
<br />TWO - 37 Gal Tub (Bio) (4.9 cu R)
<br />6.2, PGII
<br />Cu Ft.
<br />M
<br />Gli Regulated Medical Waste, n•o.s,,
<br />1 44 Gal TUb(Blo) (5.9 cu ft)
<br />6.2.
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n,o.s.,-{,�
<br />1 u
<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 />LLI
<br />Medical Waste, n.o.s..
<br />23PGil
<br />WB434,__-_ AAsP43- Gal Tub(5.7CUFT)
<br />Regulated
<br />6
<br />____)/WC434 --)
<br />Cu Ft.
<br />,Regulated Medisai Waste, n.o.s.,
<br />(
<br />Ka_ . Bia erns Cardboard BOX 4.3 Cu ft)6.2,
<br />6.2PG
<br />. PGII
<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
<br />Cu Ft.
<br />3. Generator's Certification: `t hereby declare that the contents of this consignment are fully and accurately TOTALS 10,s
<br />Cu Ft.
<br />descrabove by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />lbad
<br />r cis in proper condition fqr transport according to applicable International and natioon rnmental regulations"
<br />Prin yped Name r Slgnatu 2j(�
<br />ate
<br />W
<br />4. TR ORTER 1 ADDRESS:
<br />SteriCj(te, ina: ' ❑ Thi$ IS +� rough S1ytpiT!@rtf
<br />Phone #($8�)7 -74 2
<br />Applicable Permit Numbers:
<br />4135 W. SMI Ave
<br />Hauler Reg# 34.04
<br />2 2
<br />Fresno,CA 93122
<br />m
<br />per,
<br />TRANSPORTER CERTIFICAT N: Receipt of medical waste as descri a
<br />w
<br />Printriype Nam Signature
<br />Date
<br />5. INTERMEDIATE HA ER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />sl
<br />�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVType Name Signature
<br />Date
<br />0. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Permit Numbers:
<br />< oc
<br />UJ J
<br />2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Applicable
<br />y
<br />x�x
<br />—
<br />Print/Type Name ' Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. Dealgnnted Facility: 88. Altemate Facility: RC, Altemate Facility:
<br />8D. Alternate Facility:
<br />Steri c. Autoclave Sterlc de -Inc. Incinerate Stericycle, inc. Aqtociave
<br />Covanta Marlon, inc incinerate
<br />a
<br />4135 W. SWIt Ave 90 N. Foxboro Drive 1551 Shekon Drive
<br />4850 Brooklake,�R4ad NE
<br />Fresno, CA : tRNeofTiz North Sak•L•ake, UT 54054., Holster, CA 95023
<br />Brooks OR 97305
<br />(866)783-74 (801)936-1171. (888)783-7422
<br />(505133-9890
<br />Z
<br />TS/OST-22 3A -4481.1A-38 ;, TS/OST'-23
<br />Permit # 364
<br />SEP J 1 21m)
<br />'
<br />TREATMENT FACILITY: I certify that I have been auitiorizdd by the applicable state agency to accept untreated medical wastes and that I have
<br />H
<br />received the abovrastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />tanrred containers, CU III to : Brooks, OR
<br />Transferred containers, cu R to : N. Sak Lake, UT
<br />+r : ►Jill
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