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. ��` }.! �.a j MEDICAL WASTE TRACKING FORM NUMBER
<br />w.1
<br />'i a i�.yclee ASE OF EMERGENCY CONTACT: CHEMTREC 1.800-42 STANDARD MANIFEST 001.10.06 -STD
<br />J
<br />Rowe #: 123 — 20 CUSTOMER NO. 21132 MOROO MDE
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN
<br />GILL MEDICAL CENTER
<br />1617- N CAL11PCRKA ST
<br />STOCKT011f CA 95204— 6117
<br />(209) 451-9031
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATiON #
<br />2A. DESCRIPTION OFWASTE 20. CONTAINERTYPE
<br />6 23PGll Regulated Medical Waste, n,o s., TB04 — 29 Gal Tub (Bio) (3.7 cu ft)
<br />23291, Regulated Medical Waste, n
<br />6 2, PGp ,o.s„ TH49 — 37 Gal Tub (Bio) (4.9 cu tt)
<br />6
<br />-X UN3291 Regulated Medical Waste, n o.s„ Hl _ 44 Gal Tub ('Bio) (5.9 cu tt)
<br />O 6,2, PGIl
<br />d UN3291, Regulated Medical Waste, n o,s„ Gal Tub (2.70UPT)
<br />cc, 6,2, PGII
<br />W, UN3291 Regulated Medical Waste, n,o.s.,
<br />Z 6.2, pGll
<br />(5 UN329i Regulated Medical Waste, n,a.s„
<br />5.2, PGtI WB4S— ( } f tste43— ( ? f Wt;43 { ) tial Tub (5.7Ct7E T)
<br />UN3291 Regulated Medical Waste, n,o.s,,
<br />6,2, PG11 KR -- Biosystems Cardboard Box (4.3 Cu ft)
<br />Regulated Medical Waste,
<br />3. Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately I TOTALS
<br />�laa»ctbed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In a
<br />11respects in proper cored��fAM;�PA
<br />�n for transport according to applicable international and nation vernmental regulations:'
<br />`o. �a41:, '4 KleTe \ �n �xarJr P. t
<br />A+,JWSPORTER 1 ADDRESS;
<br />r�u Stericycje, inc.
<br />4135'W. Swift Ave
<br />—a.. Fresno,CA 93722
<br />a TRANSPORTS ERTIFICATIO : Racal
<br />PrinVlype Name
<br />Ego
<br />5._INTERMEDiA ND R 2 /TRANSPORTER
<br />5/291/2018
<br />2C. iNO.OF 2D. VOLUME
<br />CONTAINERS
<br />Cu Ft.
<br />Cu Ft.
<br />Cu Ft.
<br />Cu Ft
<br />Da_)�7) 2-411 k
<br />® This is a Through shipment Applicable Permit Numbers -
<br />Hauler Reg# 3400
<br />of medical waste as descn ed abo a.'0--
<br />Signature Date V
<br />ADDRESS: Phorja #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printilj+pe Name Signature
<br />Date
<br />m 6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone M
<br />Applicable Permit Numbers,
<br />m INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />z
<br />fPdntltype Name Signature Data
<br />Li
<br />u
<br />h
<br />u�
<br />DISCREPANCY
<br />6AA. Dostgnated Facility:
<br />Stel'Icycle, inc.
<br />4135 W,SWItA"
<br />Fresno, CA 93722
<br />(898)783-742:
<br />TS/OST 22 DAW--"6 Qff1
<br />8B. Alternate Facility:
<br />tricycle, Inc.
<br />N. Foxboro Me
<br />rth Salt Lake, UT 84054
<br />ilj938-1171
<br />A 8C. Alternate Facility:
<br />Stericycle, Inc.
<br />1551 Shelton Drive
<br />Hollister, CA 95023
<br />(888)783-7422
<br />TSIOST 83
<br />18D. Alternate Facility:
<br />Covanta Madon,lnc
<br />4850 Brooklake Road NE
<br />Brooke, OR 97305
<br />(506)393-0890
<br />Permlt # 364
<br />TREATMENT F YITQ901,018that'l have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br />received the ab indicate�d{/-wastes in accordance with the requirement outlined in that authorization.
<br />Pnnt/rvge Name
<br />'transferred containers, cu ft to
<br />
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