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,{{., MEDICAL WASTE TRACKING FORM NUMBER <br />0..*.* I.eric CIe� ASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424* STANDARD MANIFEST 001 -10 -06 -STD <br />Y Rot 0- 123 — 15 CUSTOMER NO. 21132 MDFROOKQ81 <br />__.... _.._ ORIGINAL <br />1. Generator's Name}, Address and Telephone Number <br />ATTNp 111 I 1 1 IN I 11111111111111111111111111111111111111111111 <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STCMTOV, CA 95204— 6117 <br />(209) 451-9031 <br />6/26/2018 <br />CUSTOMER NUMBER (5111852-001 GENERAmws REGISTRATION N <br />2A. DESCRIPTION OFWASTE 2B. CONTAiNERTYPE <br />2C. NO, OF <br />2D. VOLUME <br />U Regulated Modica] Waste, n.o.s., H04 — 28 Coal. Tub (Rio) (3.7 cu ft) <br />CONTAINERS <br />6.22,, pGl PGI <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., TB49 — 37 Gal. Tub (Bio) (4.9 Cu.ft) <br />6.2, PGII <br />Cu Ft. <br />0: <br />UN3291 Regulated Medlcai Wanle, n.o. , TBl — 44 Gal. Tub (Bio) (5. 9 Cul ft) <br />p <br />6.2, PGI <br />Cu Ft. <br />UN3291 Regulated Madfcal Waste, n.o.s„ TB21— ( } /TP15— { } %TXE5— ( } 2Ct Gal Tub (2.7GTZFT} <br />XI" <br />6.2, PGI1 <br />Cu Ft <br />UJ <br />-Z, <br />UN3291 Regulated Medical Wnto, n.o.s., <br />6.2, PGI <br />Cu Ft. <br />U <br />UN3291 Regulated Medlcai Waste, n.o.s., <br />6.2, PGI 43— () /Tr71343-- { ) /TdC43— () sial. This (5.?CUE'T) <br />Cu Ft. <br />6 23PGI� Regulated Medical Waste, n.o.s„ — Biosystems Cardboard Box (4.3 cu ft) <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s,, <br />6.2, PGIJ <br />Cu Ft. <br />UN3291 Regulated Medical Watle, n,0.s„ <br />6.2, PGI <br />Cu Ft. <br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />�✓ Cu Ft. <br />d ed above by the proper shipping name, and are classified, packaged, marked and labelled/ lacarded, and <br />Ina respects In proper condition for transport according to applicable international and na rnmental regulations" <br />w <br />j <br />� <br />intedlryped Nam t Ig ature <br />ate <br />ANSPORTER 1 ADDRESS:PhonO$66) <br />Steric' rale, Inc. This a a a T uqh Btugmcnt <br />—7t12Z <br />Applicable Permit Numbers: <br />4135f Swift: Ave <br />Hauler Reg## 3400 <br />N <br />Fresno,CA 93722 <br />q� Q <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as de abed b e. <br />W <br />­ <br />Print/Type NSigns r <br />Date <br />5. INTERMEDIATE MAN R 2 /TRANSPORTER 2 ADDRESS: <br />Phone # <br />NgApplicable <br />Permit Numbers: <br />� <br />INTERMEDIATE HANDLER i TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrintiType Name Signature r <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone #: <br />o <br />Applicable Permit Numbers: <br />0. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Q�x <br />fE <br />Print/Type Name Signature <br />Date <br />7. QI+ CREPAN INDICATION <br />}. <br />A. Designated Facility:8B. Alternate Facility: ® 8C.Aftemate Facility: E] 8D. Aitemate Facility: <br />.tet <br />dcycle, Inc. Sterlcycle, Inc. <br />4135 W. Wt AV* <br />Cavanta Marlon,inC <br />4 N. Foxboro Drava 1661 Shatton Drava <br />4850 Brooklako Road NE <br />t6t <br />z <br />Fresno CA 93722 orifi Salt Lake, UT 84054 Holileter, CA 85023 <br />�N <br />(866)7 3-7422 I�Egf u 8Q1)936 -i171 (866)783-7422 <br />Brooks, OR 97305 <br />(60S)S93-0880w <br />TStOST 22 SA 4481JA-36 TSIOST 83 <br />Permtt#364 <br />Pill 26 2010 <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 />F- <br />received the above in'tcjt�es in accordance with the requirement outlined in that authorization. <br />Printflype Name Signature <br />Date <br />wane etT@ containers, CU ft to <br />__.... _.._ ORIGINAL <br />