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e {. — --- — — ' MEDICAL WASTE TRACKING FORM NUMBER
<br />®® we 'ILeric C�E„Ji` ASE OF EMERGENCY CONTACT: CHEMTREC 1-880-42 STANDARD MANIFEST 001 -10 -06 -STD
<br />Y Route #« 123 _ 21 CUSTOMER NO. 21132 MOFROOKPAD
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<br />1. Generator's Nrra�tpm�Ae(, Address and Telephone Number
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<br />III1111111111111111111111111111111111111111111111111111
<br />GILT, MEDICAL CENTER
<br />1617 N CALIFORNIA 5T
<br />STOCKTOW, CA 95264- 6117
<br />(209) 451-9031
<br />6/19/2018
<br />CUSTOMER NUMBER 611-1852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO, OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI
<br />Bt)4 - 28 Gad Tub (Bio) {3.7 cu tit)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291 'Regulated Medical Waste, n.o,s.,
<br />6.2, PGII
<br />D49 - 37 Gal Tub (Bio) (4.9 Cu 'Cil)
<br />Cu Ft.
<br />W
<br />232911 Regulated Medical Waste, n.o,s.,
<br />gy4 — 44 Gad. Tub (Bio) (5.9 Cu ft)
<br />�
<br />Cir"
<br />L
<br />6
<br />Cu Ft
<br />Q
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />E
<br />B2.1— ( 3 TP15— { } TY15— ( ) 20 Gal Tub (2.7CUFT)
<br />6.2, PGI
<br />Cu Ft
<br />W
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />Z
<br />6,2, PGII
<br />Cu Ft.
<br />Ill
<br />Medical Waste,
<br />UN3291 Regulated
<br />Regulated n.o.s.,
<br />43— { } /Wp43— { ) /Wc43- () tial Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste,n.o.s„
<br />62, PG1l
<br />— Biosysts Cardboard Box (4.3 cu ft}
<br />em
<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. Generator's Cortiflcation: "I hereby declare that the contents of this consignment are fully and accurately T:O ATA S ®
<br />1 5 F Cu Ft
<br />descrlbed above by the proper shipping name, and are classified, packaged, marked and labeliewplacarded, and
<br />are in all respects in properc on for transport according to applicable infernationai and national governmental regulations."
<br />I
<br />'l Printed/Typed Nance Signature
<br />Date {�
<br />a
<br />4. TRANS PORTER 1 ADigRESS: g- q
<br />Stec CyOle, inc. U This is a Through ipme
<br />Phorfp966) 783-7422
<br />Permit Numbers:
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<br />Applicable
<br />4135 W. Swift Ave Hauler Reg# 3400
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<br />'E'resno,CA 93722
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<br />TRANSPORTER CRRTiF�I{CAjTII�ON::Renceipt of medical waste as described above.
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<br />PrinUType Name P/YL�J V r _/ �1 � iG Signature —Date
<br />,=—(-
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />h
<br />Applicable Permit Numbers:
<br />be
<br />OC]
<br />d I
<br />INTERMEDIATE HANDLER lTRANSFORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrinUiype Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/lype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility, E] 8B. Attemate Facility: E] 8C. Altemate Facility:
<br />F1 81). Alternate Facility:
<br />Stericycie, Ina. dcycle, Inc. Stedcycle, Inc.
<br />Covanta Marlon,lnc
<br />4135 K Swift AVe 30 N. Foxboro Drive 15551 Shelton DM
<br />4850 Brooldake Road NE
<br />Fresno, CA 93722Orth Salt Lake, UT 84054 Hollister, CA 95023
<br />Brooks. OR 97305
<br />801)93& 1171 (866)783.7422
<br />(505)393-0890
<br />W(866)783-7422
<br />TSIOST22 DACEMINEOIIM A'AA8/,}A-36 TSIOST=83
<br />Perm1#364
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<br />TREATMENT ��p1��1��..In�yql gg��rr��rr that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />�`fIn8ic`atddtt�8dstes in that
<br />received the ab�4 in accordance with the requirement outlined authorization.
<br />Print%pe Name Signature
<br />Date
<br />oris erre containers, cu ft to
<br />rte^
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