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MEDICAL WASTE TRACKING FORM NUMBER
<br />•e:®tericycl #E .E15!TENCY SONTACT: CHEMTREC I -BOG -42 STANDARD MANIFEST 001 -'10 -06 -STD
<br />CUSTOMER NO. 21 2 MI}E'AQQK�M3
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN.
<br />GILL NIENCAi.. CENTER
<br />I4
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204-6117
<br />(249) 461-9031
<br />914/2018
<br />CuBTOMER NumeleR GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB04 - 28 Gal Tub (Blo) (3.7 ou ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TW- 37 GalU o CU
<br />6.2, PGII
<br />Cu Ft.
<br />aC
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />44 Gal ub( o) cu )
<br />®
<br />6.2, PGII
<br />-' Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />�I"
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Z
<br />6,2, PGIILU
<br />Cu Ft.
<br />6 23PGIj Regulated Medical Waste, n.o.s.,
<br />WB434_)/WP434 ___ )NVC43-{ ) Gal Tub(5.7CUFT)
<br />Cu Ft.
<br />UN3291,Regulated Medical Waste, n.o.s.,
<br />KR - Biosystems Cardboard Box (4.3 cu ft)
<br />,
<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: "I hereby declare that the contents of this consignment are fully and accurately T®TALS ®
<br />Cu Ft.
<br />above by the proper shipping name, and are classified, packaged, marked and labeiledlp ed, and
<br />II espects In proper condition for transport according to applicable International and nati gov mental regulations"
<br />P ' tedfryped Name ignature
<br />ate
<br />�
<br />spoRrER DDRE_- S$_ Inc. This is a Through Shipment
<br />�eRl ' n6.
<br />Phone #.
<br />4135 W. SWft Ave
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
<br />°a
<br />Fresno,CA 93722
<br />4 d
<br />TRANSPORT TIF G : Receipt of medical waste as describe b
<br />Print/Type Name Signature
<br />Date
<br />S. INTERMEDIATE HANDEEFT2 fTFIANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />g
<br />a
<br />ee"ee I
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />o m
<br />Applicable Permit Numbers:
<br />&0 it a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Q�x
<br />z
<br />Im —
<br />PdntlT a Name nature
<br />Yp Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. Designated Facility: 88. Alternate Facility: I] 8C. ANernate Facility: 8D. Attemate Facility:
<br />J
<br />e ink. Auto Stericvck, Inc. Incinerate Steri Inc. Auto
<br />Covanta tvt'arion, Inc Incinerate
<br />U4
<br />4136 ,Swift Aue leo N. Foxharo Drive 1661 Shelton Drive
<br />4864 Brooktake Road NE
<br />rrasnv,rAA93722 North Gott Lake, UT 84054 Mobster, CA 95023
<br />(fttltij78 7 (601)236-1171
<br />Brooks OR 97305
<br />.ANNEOI Ttz (966)783-7422
<br />f6A6i9�3-i?69ii
<br />W
<br />TS/QST-223A&1JA-36 TS/OST-83
<br />Perrnli # 364
<br />a
<br />SEP 0 4 2O1
<br />Lu
<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 />►- 1
<br />received the abQQW , d wastes in accordance with the requirement outlined in that authorization.
<br />PrinVType NameSIqnAt
<br />Date-W-pr—
<br />CU
<br />7 0
<br />Transferred containers, cu ft to : N. Sak Lake, UT
<br />
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