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MEDICAL
<br />WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 601,10.06
<br />.81)II f2A
<br />a, rB telricycle° ASE OF EMERGENCY CONTACT: GHEMTREC J.,,,_424,*
<br />-STD
<br />°
<br />✓ Route #: 123 — 21 CUSTOMER .21 2 MDFROOKNDE
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN-. fit 11ff111f( I,fl f fill f X i 1 tl f I 11f
<br />GILL MEDICAL CEVXER
<br />1617 IV CALIFORNIA ST
<br />STOCKMN, CA 95204- 6117
<br />(209) 452-9031
<br />6/5/2018
<br />CusTomim NUMBER 6111852-001 GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medlcal waste, n.o,s.,
<br />BOO ® 28 tial Tub (Bi.o) (3.7 cu tt)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Fl.
<br />UN3291 Regulated Medlcat Waste, n.O.s.,
<br />6,2, PGIICu
<br />T849 — 37 Gag Tub (Bio) (4.9 au tt;)
<br />Fi
<br />Q
<br />623 PGII Regulated Medical Waste,tl.o.s
<br />Bl _ 44 Gag Tub(Bio) (5.9 cu ft;)
<br />`
<br />Cu Ft
<br />Q
<br />UN3291 Regulated Medial Waste, n.a.s.,
<br />� 29
<br />TB2.1,— { } TP15— { } TY25— ( } 20 Gag Tub (2.70UPT)
<br />a
<br />I
<br />Cu Ft
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<br />W
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, 11
<br />Cu Ft.
<br />UN 291
<br />23PGRegulated Medical waste, n.a,s„
<br />43-- () /WE43-{ ) /i�1cd3- { ) tial TUb (5.7CUFT)
<br />Cu Ft.
<br />U2Regulated Medica! Waste, n.o.s.,
<br />s.2,, FGII
<br />PGI
<br />rstetlts _ Bio�Cardboard Sox (4-2 au Et)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, 111
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n•o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALSv
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labeiled/placarded, and
<br />In proper condition for transport according to applicable international and Wali r gutatlans
<br />jespectis
<br />9
<br />ediTyped Name Ign r
<br />A. SPORTER 1 ADDRESS:
<br />Stetriryale, Ina. TbI xs a Thr l#h shipment
<br />!n
<br />Phor4966) —7422
<br />Applicable Permit Numbers:
<br />4135 W..Sw�ft Ave eaulex Reg# 3400
<br />4 0
<br />F>reehta, GA 93722
<br />TRANSPORTS ERT FICA N: Receipt of medical waste as desen a"��
<br />x
<br />PrinVType Name Signatur
<br />Daie
<br />S. INTERMEDIATE HANDL R DTRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers'
<br />a
<br />QU1
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnMpe Name Signature
<br />Date
<br />acc
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Q
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />PrfnUrype Name Signature
<br />Date
<br />7 DISCREPANCY INDICATION
<br />8A. Designated Facility: 89. Alternate Facility: ❑ 8C. Alternate Facility:
<br />❑ 813. Alternate Facility:
<br />Rte cle, inc. cle, Inc. Stericycle. Inc.
<br />Covanta Madon,inc
<br />4186 Swift AVO 0 N. oXboro OrNe 1651 Shelton Drive
<br />�CA
<br />4850 Brooldiii Road NE
<br />ft,
<br />Fresno 83722 Safi Lake, tft' 8QEI84 Hollister, CA SS023
<br />Brooks, OR 97305
<br />1866)W7422 8t IMS -1871 (866)783-7422
<br />(605)393.0880
<br />TS!®Si�22 D A y 0 BIJMBS'T15IQST 83
<br />PernlR 0 $64
<br />cc
<br />TREATMENT FAQ I� 1A�g O&Mat I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />1—
<br />received the abo icated S in accordance with the requirement outlined in that authorization.
<br />Printrtype Name AAA.442` Signature
<br />Date
<br />cu If to
<br />ORIGINAL.
<br />
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