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40 e *AflOFaRGNCCONTACT: GHEMTRC 1-BOU•424- MEDICAL WASTE TRACKING FORM N
<br />UMBER
<br />JtpLJLeSTANDARD MANIFEST 001.10.06 -STD
<br />.iQ
<br />CUSTOMER NO. 21132 MD RO Q KeS.3 S
<br />Ali
<br />I ransTerrea Containers, CU n 10 :
<br />1. Generator's Name, Address and Telephone Number
<br />.
<br />ATTN':
<br />1111111111111111111111111111111111111111111111111111111
<br />GILL MDICAL GEN=
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031
<br />7/10/2018
<br />CUSTOMER NUMBER (511177)2-001 GENERATOR'S REGISTRATION
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINERTYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T'B04 - 28 Gal Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB49 — 37 Gal Tub (Dio) (4.9 cu ft)
<br />6,2, PGII
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />'81 - 44 Gal Tub (Bits) (5. 9 cu it)
<br />v Ca Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />s — TP TY — { (gal Tub (2.7CUF'T)
<br />a
<br />6.2, PGIi
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.os.,
<br />Z
<br />6,2, PGI!
<br />Cu Ft.
<br />6 23 916 Regulated Medical Waste, n.os.,
<br />WB43— ( } !wT.42— { } /WC43•- ( } Oul Tub (5.7cu r'Tj
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />KR .. Biosystems Cardboard Box (4.3 cu ft}
<br />6.2, PGII
<br />--
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.os.,
<br />6.2, PH
<br />Gu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />Cu FL
<br />3. Generator's Certification: ul hereby declare that the contents of this consignment are fully and accurately TOTALS I1
<br />Cu Ft.
<br />desc ed above by the proper shipping Hams, and are classified, packaged, marked and iabeiled/plaCarded, and
<br />ar a spects in proper condition for transport according to applicable international and nation ernmental regulations."
<br />v iArinto
<br />ignature
<br />/Typed Name;
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<br />4. TRANS RTER 1 ADDR S ;
<br />Ste>rioyCe, Inc. This is a gh Shipment
<br />Phon b .St 2L
<br />> f-
<br />4135 W. Swift AveApplicable
<br />Permit Numbers:
<br />a a
<br />Hauler
<br />Reg# 3400
<br /><.Nn
<br />I'xetsno, CA 93722
<br />°C,'o�c
<br />TRANSPORTERIFICAT pt of medical waste as described a.
<br />r
<br />Printilype NameZ?aj ko Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS;
<br />Phone #:
<br />sm
<br />Applicable Permit Numbers:
<br />RB
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />°w
<br />I�
<br />Print/i-ype Name Signature
<br />Date
<br />6. iNTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />g
<br />Applicable Permit Numbers:
<br />M.2 a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />� x
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. Designated Facility: 8$. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility:
<br />Ste cle, Inc. 3tedcycle, Inc. Stedcycle, inc.
<br />Covanta Madon,lnc
<br />vFV4135
<br />W. Swift AVG 30 N. Foxboro Drive 1551 Shelton Drive
<br />4850 Brooldske Road NE
<br />Fresno, CA 93722 4orth Salt Lake, UT 84054 Hollister, CA 33023
<br />Brooks, OR 97305
<br />f—
<br />(866)783-742 MNEoRM 801)936-1171 (866)783-7422
<br />(605)393-0890
<br />tZii 13,�.
<br />TS/OST-22 A 4481JA-36 TSIOST 83
<br />Permit* 364
<br />fTREATMENT
<br />Agltiy:12artig that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />!—
<br />received the above i1}dicd wastes in accordance with the requirement outlined in that authorization,
<br />�&01
<br />Printfrype Name Signature
<br />Date
<br />Ali
<br />I ransTerrea Containers, CU n 10 :
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