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Stericycle° <br />MEDICAL WASTE TRACKING FORM NUMBER <br />ASE OF EMERGENCY CONTACT: CHEMTREC 1 -800 -424 - STANDARD MANIFEST 001.10 -06 -STD <br />Route #; 123 - 18 CUSTOMER NO. 21132 MD){ROOI TIY <br />1. Generator's Name, Address and Telephone Number <br />ATTN <br />GILL MEDICAL CETITER <br />1617 K CALIFORNIA ST <br />STOCKTOW, CA 95204. 61.17 <br />(289) 451-9031 <br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE <br />UUN32291I1 <br />Regulated Medical Waste, n.0 -s. B04 _ 28 Gal Tub (Bio) (3.7 Cu -ft) <br />UN3291 Regulated Medlcai Waste, n.o s , B4 9 _ 37 Gal Tub (Bio) (4.9 CU ft) <br />6,2, PGII <br />CC UN3291, Regulated Mlldical Waste, n.o.S.,j 44 Gal, Tub (Bil,) (5.9 Cbl ft) <br />® 6.2, PGII <br />1---UN3291 Regulated M(ldleal Waste, n.o.s., B21-� ( ) /TP15— ( ) ITY15— ( ) 20 Coal Tub (2.7CUFT) <br />6,2. PGII <br />W UN3291 Regulated Mildicai Waste, n.o.s., <br />Z 6.2, PGII <br />UJ <br />UN3291 Regulated Mgdical Waste, n.o,s. Baa_ { ) Gal Tub (5.70UFT) <br />UN3 91 Regulated Medical Waste, n.o.s., _ Biosystems Cardboyd Box (4.3 cu Et) <br />7/17/2018 <br />20. NO. OF 2D. VOLUME <br />CONTAINERS <br />Cu <br />Cu <br />Cu <br />UN3291 Regulated Mt dfcal Waste, n.o,s., <br />6.2, PG1I Cu Ft. <br />UN3291 Regulated Medical Waste, n.o $., <br />6.2, PGII Cu Ft <br />3. Generator's Cartlfication: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® `, Cu Ft. <br />desC ed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />1 Ina respects In proper condition for transp it according toapplicableinternational and nZn,et:06��.. <br />rnmental regul4dons." <br />DateI- <br />4.TRA PORTER 1 ADDRESS: <br />Stericycle, Inc. This is a Through shipment <br />CC 4135 R. Swift: Ave <br />< a Frerina,CA 93722 <br />(n <br />a TRANSPORTED CERTIFiC TiON: Receipt of medical waste as desenb a <br />PrinViype Name Signature <br />S. INTERMEDIATE I-IANDLEK 27 TRANSPORTER 2 ADDRESS: e/ <br />N INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />- Print/Type Name Signature <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />n�#e 7-17-te <br />Phone S <br />Applicable Permit Numbers: <br />Date <br />M S. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #: <br />3 Applicable Permit Numbers: <br />aw0 <br />a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinMpa Name Signature Date <br />7. DISCREPANCY INDICATION <br />BA. Dssignatod Facility: <br />❑ 813. Altemate Factgty: <br />❑ 8C. Alternate Facility: <br />SterlcycT�,'irt>a--Stertcycle, <br />4135 W. SW ft AVe <br />Inc. <br />90 N. Foxboro Drive <br />a^tericycle, Inc. <br />1551 Shelton Drive <br />ANOWCA 93722 <br />-7422 <br />TStOST-22 0A.l,EARNEOiTIV <br />I lofth Salt Lake, iii' 840 <br />801)936-1171 <br />A-446h1A-8$ <br />Hollister, CA 85023 <br />(806)763-7022 <br />TSIOST-83 <br />IJ 80. Altemate Facility: <br />Covants Marlon, )no <br />4850 ElrooWake Road NE <br />Brooks, OR 97305 <br />(605)393-0880 <br />Permit# 384 <br />TREATMENT FAUITI 7c20f hat I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />received the above Indicated wastes in accordance with the requirement outlined in that authorization. <br />Printrtype Name Signature Date <br />ORIGINAL <br />