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MEDICAL WASTE TRACKING FORM NUMBER
<br />• ®® @CiC�/C @@ Rau eSE F E J:TENCYYgNTACT: CHEMTREC 1-800.424- STANDARD MANIFEST 001 -10.06 -STD
<br />J 11 SS 99 CUSTOMER NO.211 MDFROOK'SO
<br />ORIGINAL
<br />i
<br />1. Generator's Name, Address and Telephone Number t'Mill
<br />1111111111111111
<br />I1 IATTN:II
<br />lIII
<br />GILL NEDICAL, CENTER
<br />1617 N CALIFORNW ST
<br />STOCKTON, CA 95204- 6117
<br />(209)451-9031
<br />8/28/2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />29. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />+� _ +�$ Gal Tib Bl0 3.7 CUR
<br />(Bic) ( )
<br />CONTAINERS
<br />6.2, PGA
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<br />UN3291, Regulated Medical Waste, n.o.s,
<br />- 37 Gal Tub (Bio) (4.9 cu 0)
<br />6.2, PGII
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<br />6 23PGij Regulated Medical Waste, n.o.s.,
<br />IV 44. Gal Tub(Bio) (5.9 cu #)
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<br />®
<br />UN3291 Regulated Medical Watts, n.os.,
<br />T8214 _„)fTP154 }/TY15-(�,�,,,,'20 (sal Tub(2.7CUFT)
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Watts, n,o.s„
<br />6.2, PGII
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<br />6.2, PGII Regulated Medical Watts, mos.,
<br />34__J/WP434__)/WC434_„_,_) tial Tub(5.7CUFT)
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<br />6 2, PG j Regulated Medical Waste, mos,
<br />KR_ - BIO ems Cls card BOX (4.3 Cul ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.os„
<br />6.2, PGII
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<br />UN3291 Regulated Medical Watts, n.o.s.,
<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
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<br />de above by the proper shipping name, and are classified, packaged, marked and labeiled/piso ad, and
<br />II aspects In proper condition for transport according to applicable international and natio mental regulations."
<br />)(Pjntedqyped
<br />2
<br />Name Signature
<br />Date
<br />SPORTER 1 ADDRESS:
<br />St I11C. ❑ This is oUgh Shlpr11BI11
<br />Phone
<br />Applicable
<br />4135 W. SwIA Ave
<br />Permit Numbers:
<br />Hauler Reg# 3400
<br />MN
<br />Fresno,CA 93722
<br />a 44
<br />TRANSPORTER CERIIFICATtO I: Receipt of medical waste as descri
<br />t
<br />~
<br />Pdnt/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDL / RANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typs Name Signature
<br />Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />CC
<br />Applicable Permit Numbers:
<br />W
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />rz=
<br />Printlrype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />CAk Designated Facility: 8B. AMemale Facility: 8C. Ahem rte Facility:
<br />8D. Altemate Facility:
<br />PStets
<br />-41
<br />Aut a Inc. Incinerate Sterifwyde, Inc. Auto
<br />S"t Atre
<br />Cownta Nbtion. Inc Incinerate
<br />4136 W. 0 N. oxboro Drive 1551 Shellion Orin
<br />4850 Brooldake Road NE
<br />rrtmil a, CA 1*722 h Lake, UT 84064 Hftal Mer, CA 96023
<br />Brooks OR 97305
<br />(36611183-7422
<br />ST -7 22 1) LE ANNE OV 801) �0-1171 (866)783-7422
<br />(505)363-0890
<br />TS/OST-83
<br />Permit * 364
<br />W
<br />AUG211
<br />2 8 2010
<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 />FF-
<br />received the above indiopt%wmle/s in accordance with the requirement outlined In that authorization.
<br />Print/Type Name Signature
<br />Tvansferrud
<br />Date
<br />: ,
<br />Trams ed containers, cu t to : N. Sal Lake, LIT
<br />ORIGINAL
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