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eT MEDICAL WASTE TRACKING FORM N <br />UMBER <br />I (YERGEN Y CONTACT; CHEMTREC 1•$0042 0 STANDARD MANIFEST001.10.06•STD <br />®°®® Sier14\LV RO SC q <br />CUSTOMER NO. 21132 MD ROOKVXi3 <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOCXTON, CA 95284— 61.17 <br />(209) 451-9032 <br />8/7/2818 <br />CUSTOMERNUMBER 61.11852-001 GENERATOR'sREGISTRATION# <br />2A. DESCRIPTION OF WASTE 213. CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medica! Waste, n.o.s„ rB04 — 28 Gal Tub (Bio) (3.7 ett ft) <br />CONTAINERS <br />6.2, PGI) <br />Cu Ft. <br />6UN329.21 1� Regulated Medical Waste, n.o.s., $ — 37 Gal. Tub (Hie) (4.9 Cu ft) <br />Cu Ft. <br />M <br />6 23PGN Regulated Medfeaf Waste, n.o.s.tZ44 Gal. Tub(Bio) (5.9 cu ft) <br />� Cu Ft <br />cct"' <br />UNS291 Regulated Medical Waste, n.o.s.) TP15— ( ) TY15— t ) 20 >ael Tub (2.7CUPT) <br />6.2, <br />PGI) <br />Cu Ft. <br />W <br />UN3291 Regulated Medical Waste, n o.s., <br />6.2, PH <br />Ou Ft <br />IZ <br />C7 <br />U2329 j Regulated Medical Waste, n.o.s, 43— ( /WF42— ( ) /WC42 - ( ) tial. Tub (5.?CUPT) <br />Cu Ft <br />& 2, PGII Regulated Medical Waste, n.o.s., — Biosystems Cardboard Box (4.3 au ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PSI) <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.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 TOTALS <br />® Cu Ft. <br />dascidiW above by the proper shipping name, and are classified, packaged, marked and labelled/piacarded, and <br />n all rf3$pacts in proper condition for transport according to applicable international and nation mental regulations" <br />s p <br />1 <br />7 1,1P <br />Pr tedRyped Name gn Lure <br />i <br />cc <br />ui <br />SPORTER 1 ADDRESS: <br />Stericycle, Inc. ® This i.s a Throug shipment <br />Phoi("6) 78-a--7422 <br />4135 W. Swift Ave <br />Applicable Permit Numbers: <br />Hauler Reg{# 341)0 <br />MtE <br />a <br />Frc*ano,CA 93722 <br />a rn Z <br />TRANSPORTS ERTIFICATIO : Receipt of medical waste as describe above <br />'" <br />PrInt/Type Name Signature <br />S. INTERMEDIATE HANDLER 2 ITRANSPORTER 2 ADDRESS: <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />N11% !H <br />�5]� <br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: <br />Phone #: <br />W :5Ir <br />in <br />Applicable Permit Numbers: <br />a° Cl <br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />s <br />— <br />POnMpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Designated Facility: ®Be, Alternate Facility: E] 8C. Alternate Facility: <br />8D. Alternate Facility: <br />:J <br />8 dcYG 9. Inc, ricycle, Inc. S ericycle, Inc. <br />Cmiri a Marlon, Inc <br />Q <br />4135 W, SWftA" 0 N. Foxboro Drive 1651 Shelton Drive <br />4860 Bmoklake Road NE <br />r I <br />Fresno, CA 93722 orth Salt Lake, LIT 841754 Hollister, CA 95023 <br />Brooks, OR 87306 <br />Z <br />(866)783-7422 DALg NVE OFIT 801)836-it7f (866)7$3-7422 <br />(605)393-0890 <br />TS/OST 22 A-448MA-36 IOST 83 <br />Permit# 364 <br />W <br />t <br />TREATMENT FACIJ ®rtiiy <br />�t have been authorized by file applicable state agency to accept untreated <br />medical wastes and that I have <br />fo- <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />PrintrType Name Signature <br />Date <br />Transferred containers, cu fl to <br />