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®®� Stericycle®
<br />ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-42
<br />RQU' a 6: 123 - 4 CUSTOMER NO. *132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10.06•STO
<br />MDFROOKOCA
<br />1 .M&J
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: ji jj
<br />j(
<br />GILT, NEDICAL CENTER
<br />1617 N CALIZORNIA ST
<br />STOCXTON, CA 95204- 61:17
<br />(209) 451-9031
<br />6/12/2018
<br />CUSTOMERNUMBER 6711$52-001 GENERATOR'SREGISTRATtdN#
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />URegulated Modica! Waste, n.0,s.,
<br />TED4 — 26 Gal Tub (Bio) (3.7 cu ft)
<br />CONTAINERS
<br />6.22,. PGI)
<br />PGI
<br />Cu FL
<br />6 23PGII Regulated Medical Waste, n,e,s.,
<br />TB49 — 37 Gal Tub (Bio) (4.9 cu ft)
<br />Cu Ft
<br />M
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />6.2, PGII
<br />8I4 44 Gal Tub (Bila) {5.9 cu ft)
<br />O
<br />Cu Ft
<br />at"
<br />UN3291 Regulated Medical Waste, n,a.s,,
<br />6.2, PGII
<br />TE21.- ( ) /TP.15— ( ) /TY1.5- ( ) 20 tial Tub (2.7CUFT)
<br />Cu FL
<br />W
<br />UN3291 Regulated Medical Waste, n.as.,
<br />6.2, PGII
<br />Z
<br />Cu Ft.
<br />6 2, PGIj Regulalod Medical Waste, n.o.s„
<br />WB43- ( ) /W,43_ ( ) /WC43-- ( ) Gal Tub (5.7CUFT)
<br />Cu Ft.
<br />URegulated Medical Waste, n.a.s„
<br />6.22,, PGII
<br />PGII
<br />KR _ Biosystems Cardboard Box (4.3 cu ft)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.a.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />Cu F.
<br />3. Generator's Certification: '1 hereby declare that the contents of this consignment are fully and accurately TQTALS ►
<br />Cu Ft.
<br />de ed above by the proper shipping name, and are classified, packaged, marked and labeiled(pI rded, and
<br />e in respects In proper condi ion for transport according to applicable international and nation rnmental regulations"
<br />'�aOP
<br />nted/fyped fUama !! ii1�G,e, grt trrs
<br />rr
<br />SPORTER 1 ADDRESS:
<br />Phon(066) -7422
<br />StetiCycler Ina. This is a Through shipment
<br />Applicable Permit Numbers,
<br />4135 W. Swift Ave iiaul.er Reg# 3400
<br />g,N
<br />Freano,CA 93722
<br />IL
<br />TRANSPORTER TIFI ATiO ' Re�ctellpp%t of medical waste as described
<br />/
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<br />/ � �}
<br />!l�//,
<br />`edi
<br />PrIntrrlpe Name /r Signature
<br />Date
<br />S. INTERMEDIATE HANDLG 2— TR NSPORTER 2 ADDRESS:
<br />Phone #.
<br />N
<br />Applicable Permit Numbers,
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Print/Type Name Signature Date
<br />M
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone #
<br />flsq
<br />Applicable Permit Numbers:
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as descnbeclzbove.
<br />z�x
<br />—
<br />PrinUType Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facltity: Q 8B. Alternate Feoti[ty: E] SC. Altemate Fac6fty: ❑ 8D. Alternate Facility:
<br />Ste ale, Inc. edaycle, Inc. Stericycle, Inc.
<br />SWt
<br />Coventa Marlon,lnc
<br />u
<br />4136 W, t AVR 90 N. Foxboro Drive 1561 Shelton Drive
<br />4850 6rooNake Road NE
<br />Fresno CA 93722N North Salt Lake, tJT 84054 Holllster, CA 95023
<br />Brooks, OR 97305
<br />(866)763-7422 (80 1)93$-1171 (866)783-7422
<br />(58511393-0830
<br />TSiOST=22 all ANI`ME OW9 3A-448/JAr36 TSIOST 83
<br />Permt * 364
<br />L
<br />TREATMENT�`��,,p�J IL T'�,, tt����rr��% that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />the Ild�ati34t1�Tastes
<br />1•-
<br />received a1U� in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />�
<br />ranS Bice txttit,3 Hare, dr >>t ik4
<br />C:7
<br />1 .M&J
<br />
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