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f j( MEDICAL WASTE TRACKING FORM NUMBER,;I <br />ff® ®O ,Stericycl .1® ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424 STANDARD MANIFEST 001.10.06 -STD <br />Route #: 123 . 22 CUSTOMER NO. 21132 MDFROOKVVA <br />- ORIGINAL - <br />1. Generator's Name, Address and Telephone Number <br />GILT, MEDICAL CENTER <br />161.7 N CALIFORNIA 5T <br />STOCKTO-Nr CA 95204— 6117 <br />(209) 451--9031 8/14/2018 <br />CusTOMEn NUMBErt 61-11852-001 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OFWASTE 2E• CONTAINER TYPE <br />20. NO. OF <br />21}. VOLUME <br />UN3291 Regulated Medical Waste, n.o s. <br />6.2, PGII B04 - 28 Gal Tub (Bio) (3.7 CU ft) <br />CONTAINERS <br />Cu FL <br />UN3291 Regulated Medical Waste, n.o.s. B49 37 C7dl CBio) (4.9 cu Lt) <br />6.2, PGI <br />Cu Ft. <br />O6 <br />2 PGIS 3291 Regulated Medical Waste, n.a.s. Bl _ 44 Gal Tub (Bio) (5.9 Cu 1:t) <br />Cu Ft. <br />QUN3291 <br />Regulated Medical Waste, n.o,s. B21- ( ) f TP15- ( ) /TY15-- ( ) 20 eal Tub (2.7CUFT) <br />.� <br />6.2, PGI � <br />Cu Ft. <br />LFf <br />UN3291 Regulated Medical Waste, ii.e.s., <br />2 <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.e.s., <br />6.2, PGi3 1843- ( ) /WF43- ( ) /WC43- ( ) tial Tub (5.7CUFT) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s, <br />6,2, PGI ),R - Biosystems Cardboard Box (2.3 cu ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, 1`6I1 <br />Cu FL <br />UN3291 Regulated Medical Waste, n.0 s., <br />6.2, P6I1 <br />Cu Ft. <br />3. Genorator's Certification: "I hereby declare that the contents of this consignment are fully and accurately Tt?TALS ® i Cu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />ar respects in proper condition for trans ort according to applicable international and naU rnmental regulations." <br />)01 <br />W <br />,Pr edlryped Name Signature Pate <br />4.TRANSPORTER 1 ADDRESS: Pho�st)5) 783--742 <br />Stericycle, Inc. This is a Through Shipment Applicable Permit Numbers: <br />bac <br />4:135 W. SwiftAve Hauler Rett# 3400 <br />2 N <br />rtevner,CA 93722 <br />aa. Q <br />TRANSPORT ER FI ON: Receipt of medical waste as describ abo r �% <br />h <br />�( <br />Arintrlypo Name Signature Date <br />5. INTERMEDIATE HANDt.ER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />Applicable Permit Numbers. <br />° <br />INTERMEDIA`rE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printlrype Name Signature Date <br />cc <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />Numbers: <br />A <br />Applicable Permit <br />a a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a�s <br />Print/rype Name Signature Date - <br />7. DISCREPANCY INDICATION <br />y. <br />8A. Dosignatod Facility: 88. Alternate Facility: 8C. Altemate Facility: 8D. Alternate Facility: <br />Sterlcyc e, Inc, lericycle. inc. Stericycle, Inc. Crn>anta Marlon, Inc <br />41136W. SwlftAve E 0 N, Foxboro Drive 1561 Shelton Drive 4850 Brookfake Road NE <br /><w <br />Fresno, CA 83722 t lorffi Salt lake, UT 84054 iollIster, CA 86023 Brooke, OR S7305 <br />Z <br />(866)783-74221049 AMEBRnZ (3o ipara- 1171 868)783-7422 (605)393-0898 <br />TSIOST 22 : A 4481JA-38SIOST 83 Permit * 364 <br />A 1I Y� to that I have <br />TREATMENT i cerrti that I have been authorized by the applicable state agency accept untreated medical wastes and <br />'ndicatedwastes <br />I— <br />received the above in accordance with the requirement outlined in that authorization. <br />PrI.W ypo Name Signature Date <br />Transferred containers, Cu ft to <br />V <br />- ORIGINAL - <br />