|
MEDICAL WASTE TRACKING FORM NUMBER
<br />i,} er,C C'e® ASE OF EMERGENCY CONTACT: CHEMTREC 1.800-42 STANDARD MANIFEST 001 -to -06 -STD
<br />Rd M • 12� — 19 CUSTOMER NO2 MDFROOKUYN
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: 1111111111111
<br />GILL MEDICAL fXNl.'LrFt
<br />1617 F CALIFCRXIA ST
<br />STpG'ZCMl, CR 95204- 6117
<br />(209) 451-9031
<br />7/31/2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR's REGISTRATION #
<br />2A. DESCRIPTION OF WASTE 2B• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII TH04 — 28 Gal Tub (Bio) {3.7 cu ft}
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s., TB _ 37 Gag Tub {Brio} (4.9 CU tt)
<br />6.2, PGII
<br />Cu Ft.
<br />jr
<br />®
<br />UN3291, Regulated Medical Waste, n.o.s. Bl4 Gal TUb {83 0} {S. 9 QU tt}
<br />6.2, PGIf
<br />.
<br />Cu Ft
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s., g21— ( ) /TP1s— ( ) /Tyls— ( ) 20 Gal flub (2.7CUPT)
<br />a
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, nb,s.,
<br />6.2, PGII 43- ( ) /We43- { } /WC43— ( ) tial Tub (5.7CUPT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o,s., — Biosyst .s Cardboard Box {4.3 au ft}
<br />6.2, PGII
<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. Gen or's Cart[fication: "I hereby declare that the contents of this consignment are fully and acc ly TOTALS 0►
<br />marked and labeiled/p card and
<br />Gu Ft.
<br />d by a proper shipping name, and are classified, packaged, ,
<br />re ects In proper condition for transport according to applicable international and nail ern ental re ulatioTs:'
<br />rin
<br />d/Typed Name f t r F Ignature V
<br />ate 7�f
<br />a
<br />4.T PORTER 1 ADDRESS:
<br />Phor>�6) 783--7422
<br />W
<br />Stericycle, Inc. This is a Through shipment
<br />Applicable Permit Numbers:
<br />4135 B. Swift: Ave Hauler Reg>II 3400
<br />g N
<br />Freano,CA 93722
<br />CL Q
<br />TRANSPORTER CERTIFICATlO ipt of medical waste as described
<br />f
<br />'
<br />H
<br />Print/type Name Signature
<br />(�
<br />Data
<br />5. INTERMEDIATE HANDLER ! RANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />ar
<br />S
<br />�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printrrype Name Signature
<br />Date
<br />gApplicable
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Permit Numbers.
<br />WJ
<br />R 2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Daelgnated Facility: te Facltity: 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />J
<br />Sbericycla Inc. nc. Stafi4ycle, W.
<br />Covattts Marion, Inc
<br />01
<br />4135 W, SwlltAV$ w [)M 1551 Shelton Drive
<br />4860 Broeldake Road NE
<br />um
<br />Fresno, CA 93722 abe, LIT 84054 Holiist4r, CA 9 5023
<br />rN.
<br />Brooks, OR 97305
<br />(86S)783-7422 71 (866)783-7422
<br />{505)393-0890
<br />T91IOST 22 tlA4E ANN1~ 0M6 TWST 83
<br />Permit 3S4
<br />W -it
<br />TREATMENT L1 �Y I that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />in that
<br />tom--
<br />received thea=! rr3ickt stes in accordance with the requirement outlined authorization.
<br />Printifype Name—�t�,Ae�� Signature
<br />bate
<br />i•
<br />ratirt�c> Ilu 11 !0
<br />
|