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MEDICAL WASTE TRACKING FORM NUMBER
<br />4 0®to i cyGla® OASE OF EMERGENCY CONTACT: CHEMTREC 9-bot1- 424 STANDARD MANIFEST 001.10.06STO
<br />J Rotate 0: 123 -- 16 CUSTOMER No. 21132 mnFROOkXTM
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL WDICAL CENTER
<br />1817 N CALIFORNiAST
<br />MCKTON, CA 95204- 6117
<br />(209) 451-9031
<br />812112018
<br />CUSTOMER NUMBER 6111$$2 001 GENERATOR'S REGISTRATION #
<br />2A, DESCRIPTION OF WASTE
<br />2& CONTAINER TYPE
<br />2C. NO, OF
<br />2D. VOLUME
<br />s21Regulated Medical Waste, n
<br />PG1 .o.s.,
<br />CONTAINERS
<br />,
<br />,B04 - 28 Gal Tub Blo 3.7 Cu ft
<br />Cu Ft.
<br />6 N3291 Regulated Regulated Medical Waste, n.o.s.,
<br />- 37 Gal Tub (Blo) (4.9 Cil ft)
<br />Cu Ft.
<br />an,
<br />6 2, PGi� 3291 Regulated Medical Waste,
<br />- Ua1 TUb( No) (55.9 Cu ft)
<br />Cu Ft.
<br />6 2, PGII Regulated Medical Waste, n.o.s.,
<br />—mill
<br />4m a1 �r„� l -Y{ 20 dal TUb(2.7CUFT)
<br />-B214 ■
<br />_,^.�°
<br />Cu Ft
<br />UJ
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />LZ
<br />6.2, PG(I
<br />Cu Ft.
<br />UN3229911I Repulated Medical Waste, n.o.s.,
<br />43 1WC43 GSI Tub UCU
<br />Cu Ft.
<br />1.11432911
<br />2 232911 Regulated Medical Waste, n.o,s„
<br />BO 4.3 Cu ft
<br />Cu Ft.
<br />1.1143291 RogulaNd Medical Waste, n.o,s.,
<br />6.2, PG1I
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, a.e.s.,
<br />6.2, PGI)
<br />Cu Ft.
<br />3. Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately
<br />TOTALS ®
<br />i Cu Ft.
<br />desc ad above by the proper shipping name, and are classified, packaged, marked and labelled/p! ed, and
<br />I a respects In proper 5errdkton for- transp ccording to applicable International and natio ov m nlal
<br />egulatl s
<br />PrI ted/Typed Name fg tura
<br />okvate
<br />rl -
<br />rr
<br />- T PORTER 1 ADDRESS;
<br />Steri Inc, This Is Through Shipment
<br />Phone #:(866)78 7422
<br />Applicable Permit Numbers:
<br />;.
<br />0
<br />a
<br />�1t.S�tntitt Aur
<br />L135
<br />Hauler ReglP 3400
<br />Ua.
<br />)Fresno,CA
<br />83722
<br />a
<br />TRANSPORTS RTIFICATIO ' Receipt of medical waste as describe Bove.
<br />J(
<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 / RANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Ell
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Typs Name Signature
<br />Data
<br />W
<br />6. INTERMEDIATE HANDLER 3 / TRANSPCRTER 3 ADDRESS:
<br />Phone #.
<br />9§
<br />Applicable Permit Numbers,
<br />510
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Dale
<br />7. DISCREPANCY INDICATION
<br />y
<br />Bp..QRaIgnated Facility: FISH. Alternate Facility: [] 8C. Attemate Faclifty: F] 8D. Alternate Facility:
<br />3
<br />Stedwele, Inc. Autodm Steftele, Inc. Incinerate Sterlcvicle. Inc. Autociave
<br />Covanta Marlon, Inc Incinerate
<br />a
<br />u,
<br />4135 W. Swift Ave. 90 N. Foxboro Drive 1551 Shelon Drive
<br />4850 Brooklake Road NE
<br />Fresno, CA 937 60 North Salt Lake, UT 84064 HoMster, CA 85023
<br />Brooks OR 97305
<br />(888)783 -AES-- (801)836-1171 (886)783-7422
<br />(605}343-0890
<br />TSIOST-223A44$/JA-30 TS/OST-83
<br />Permit # 384
<br />TREATMEN'1"'F��I A. t'cl r ify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />r
<br />F-
<br />received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print(rype Name d Signature
<br />Date
<br />Transferred containers, ou ft to: Brooks, OR
<br />a
<br />Transferred containers, cu ft to : N. Sat Lake, UT
<br />1
<br />ORIGINAL
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