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po° Jtericycle!
<br />OASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-
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<br />Rn11tp #: 1711AI — R CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10.06•STO
<br />PAn1TDrlrtTi097
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
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<br />GILL MDICAL =11=
<br />1617 N CALIFORNIA 5T
<br />STOCKTON, CA 95204- 61.17
<br />CUSTOMER NUMBmfj ✓y-nni GENERATOR•s REGISTRATION If
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAiNERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />CONTAINERS
<br />6.21 PGI
<br />B04 .. 28 tial Tub Bio 3.7 Cu £
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<br />fi 2PGli Regulated Medica! Waste, n.o,s.,
<br />B49 — 37 Gal Tub (Bio) t4.9 cu tt
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<br />6 23291, Regulated Medical Waste, n o,s.,
<br />D14 , 44 Gal Tub Bic (5.9 Cu Tt
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<br />UN3291Regulated Medical Waste, n.o s.,
<br />2,
<br />B21— /TB3.5— C ) /TYi5- ( ) 20 Gal Tub (2.7CUFT)
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<br />PGI
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<br />UN3291 Regulated Medical Waste, n.o.s,
<br />6.2, PGI/
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />UW29f Regulated Medical Waste, n.o.s.,
<br />6.2, PGI/
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n o s,
<br />6.2, PGI/
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<br />3. Generator's Certification: "E hereby declare that the contents of this consignment are fully and accurately TOTALS'
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/piacardad, d
<br />are in all respects in proper condition for transport a rd g to applicable international and national govern a {al regulation
<br />i PrintedtTyped Name Signature
<br />Date
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<br />4. TRANSPORTER 1 ADDRESS:
<br />Pho #
<br />6� 783--7422
<br />aStericycle,
<br />Inc, This is a Th>ro h Shi ent
<br />ApplWeable ermitNumbers
<br />¢ 4
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<br />4.35 14. Swift Ave
<br />mule_ Reg#F 3400
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<br />Ftemnta,CA 93722
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<br />TRANSPORTI~R CERTIFICATION: Recelpt of medical waste as described above.
<br />H�
<br />PrEnVlype Name _ l V, /YY` Signature
<br />Date 7 3
<br />S. INTERMEDIATE` HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />NIX
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<br />1 M
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Prinirrype Name Signature
<br />Date
<br />M w
<br />6. INTERMEDIATE HANDLER 3 /TRANSPOR'T'ER 3 ADDRESS:
<br />Phone #:
<br />a
<br />Applicable Permit Numbers:
<br />N a a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z�s
<br />PrinMpe Name _ _- Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: Be. Alternate Facility: 8C. Alternate Facility:
<br />❑ 8D. Alternate Facility:
<br />v
<br />Stericycle, Inc. I Wlcyc)a, Inc. Stericyc)e, Inc.
<br />Gmnta Mar)on,lric
<br />4135 W. SWI1t Ave 90 N. Foxboro Drive 1551 Shetton Drto
<br />Fresno, CA 3SW.At_�1NE ORTIZ I Jorth Salt Lake, LIT 84054 HolllsWr, CA 95023
<br />4850 BrooMake Road NE
<br />Brooks, OR 97305
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<br />(866)783-7422 0gmra-1171 (866)783-7422
<br />22 /OST 83
<br />(605)393-0890
<br />Permft * 364
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<br />TWOST
<br />JUL 201 A-4481JA-36
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abovOadjWo,wastes in accordance with the requirement outlined in that authorization.
<br />PrinirT}+pe Name _ Signature
<br />Date
<br />Transferred eontainers, eu ft to
<br />i
<br />ORIGINAL
<br />
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