|
�" I MEDICAL WASTE TRACKING FORM NUMBER
<br />•®GPIC C�e` STANDARD MANIFEST 001 -10.06 -STD
<br />Ao* cy A$E OJT CONTACT: CHEMTREC i-601)•42
<br />I .7 ROu Q F: �23 - �1 CUSTOMER No. 22 MDVROOKLJS
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: Ef jj
<br />(i
<br />GILL MEDICAL CXNTER
<br />1617 N CALIFORNIA ST
<br />STOCIMN, CA 95204- 61.7
<br />zf.
<br />(209) 451-9031
<br />5/22/2016
<br />CusTomrRNumnER 6111852--001 GENERATon,SREGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />25• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Mgdlcal Waste, n,os.,
<br />6.2, PGII
<br />THQ4 - 28 Gal 'dub (Bis) (3.7 cu 1Et}
<br />CONTAINERS
<br />Cu Ft
<br />UN3291 Regulated Modlcal Waste, n.o.s ,
<br />6,2, PGII
<br />TB49 - 37 Gal Tub (Bis) (4.9 Cu tt)
<br />Cu Ft.
<br />UNS29lI Regulated Medical Waste, n o s.,
<br />TB14 - 4i4 Gal Tub (Bio) (5.9 Cu 'ft)
<br />`
<br />5 '
<br />ort
<br />Cu Ft.
<br />UN3291 Regulated Modica(Waste, p.0.s.,
<br />T221- E__r_ /TP15- t ) /TY1.5- ( ) 20 pal. Tttb (2 _ 7COFT)
<br />rc
<br />6.2, PGII
<br />_)
<br />Cu Ft.
<br />UJ
<br />UN3291, Regulated Medical Waste, n.0.s.,
<br />Z
<br />6.2, PGII
<br />Cu Ft.
<br />6 23 PGII RagUlatgd Medical Waste, n 1?,s.,
<br />WR43- 4 ) %M➢>,43- ( ) /WG43- ( } Gal Tub (5.7CU'T)
<br />Cu Ft.
<br />63291 Regulated Mgdlcal Waste, n.a s.,
<br />6,22, PGII
<br />- Biosystems Cardboard Bax (4.3 cu it}
<br />KIX �s
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, mos.,
<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 Certification: "I hereby declare that the contents of this consignment are fully and aceuratbiy,"\ T®TAS-S /
<br />Cu Ft.
<br />described above by the propor shipping name, and are classified, packaged, marked and labelled/placarded, dnd'
<br />are In all respects In proper co ditfon for transport accord) g to appilcable International and national governme al�regurra�tlo%n�s."/� �l ! j 22
<br />• + (/
<br />Printed/iy ed Name t Signature o/ `� U Y
<br />�
<br />+'�-'^" Date ✓
<br />gy
<br />W
<br />4.TRANSPORTER 1 ADDRESS:
<br />Stericycle, InG. ® This is a Through shipment
<br />PholiOR66) 783~7422
<br />Applicable Numbers:
<br />cc
<br />Permit
<br />4135 W. Swift~ Ave Hauler Reg# 3400
<br />aa.
<br />Fcesano,CA 93722
<br />In
<br />a d
<br />'TRANSPORTER CERTIFf ATION: Recelp of medical waste as described a4A
<br />in
<br />PrintlType Name Signature 14
<br />Date'
<br />5, INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />ons,#.,t �••
<br />MQ
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-
<br />Date.
<br />Prfnll[ype Name Signature
<br />G. INTERMEDIATE HANDLER 3 {TRANSPORTER 3 ADDRESS:
<br />Phone #.
<br />aApplicable
<br />0
<br />Permit Numbers:
<br />Ulm
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />dz
<br />-
<br />Printfrype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A.Y15aIgnated Futility: ® 813. Alternate Facility: L] 8C. Alternate Facility:
<br />086, Atlemato Facility:
<br />rlcycle, Inc. rlcycle, Inc. Siericycle, Inc.
<br />10 N. Drive 1551 Shelton Drive
<br />Covante Madon,inc
<br />4850 Brooldake Road NE
<br />C
<br />4135 W. Wit AVO Foxboro
<br />rresno,`CA 93722 4orth Salk Lake, UT 84054 Hollister, CA 95023
<br />Brooks, OR 97305
<br />(965)783-7422 801)836-1171 -(868)783-7422
<br />(SQ5)353-08810
<br />w
<br />TSIOST 22 iA ARNE ORTIZ A 448MA-36 TSIOST 83
<br />Permit # 364
<br />10TREATMENT
<br />FAC: i`�ift�i� i have been authorized by the applicable state agency to accept untreated medical wastes and That f have
<br />in that
<br />t•»
<br />received the above I atedd__w es.tn accordance with tate requirement outlined authorization,
<br />PrinVTypo Name �c Signature
<br />Date
<br />Transferred containers, cu tt to
<br />
|