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�+ YMEDICAL WASTE TRACKING FORM NUMBER
<br />�i e® .7PNFC.�IG�P.o RO�AE O�FJ ERGSY CONTACT: CHEMTREC 1-80D-424-9STANDARD MANIFEST 001.10.06 -STD
<br />° CUSTOMER NO. 21132 MURQOME
<br />1
<br />1. Generator's Name, Address and Telephone Number
<br />111111111111111111111111111 ATTC't;
<br />111
<br />j
<br />GILL FIEDICAL CENTER
<br />163.7 N CALIFORNIA ST
<br />STOMTON, CA 95204— 6117
<br />(209) 451-9031 5/15/2018
<br />CUSTOMonNUMarn 6111852-001 GENERATOR,sREGISTRATION#
<br />2A. DESCRIPTION OF WASTE 2e• CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN329i Re9Ufated Modical Waato, n,o,s., 804 — 29 Gal Tub (Hio) (3.7 Cu it)
<br />CONTAINERS
<br />6,2, PQIE
<br />Cu Ft.
<br />{
<br />UN329 � Ragafated Medlcal Waste, n,o.s, B�49 — 37 Gal Tub (Bio) (4.9 cu ft)
<br />Cu Ft.
<br />0 !
<br />UN3291 Regulated Medica! Wasfo, n o.s 9 94 Gal Tub (Bio) (5.9 au ft)
<br />6,2, PGI
<br />c. Cu Ft
<br />UN3291 11180111 lad Medical ftie, n o.s, a
<br />6.2. PGII
<br />Cu Ft
<br />WUN3291
<br />V .
<br />Regulated Modlcaf Waite, n,o.s.,
<br />6.2, Pal I
<br />UN3291 Regulated Medical Waste, n.o.s., 43_ ( ) /tae43— ( ) /WC43— ( ) coal Tub (5.7CUFT)
<br />8.2, PQIj
<br />Cu Ft.
<br />Cu Ft.
<br />UN329i Regulated Medical Wnle, n.O.s., KR _ Biosystems Cardboard Box (4.3 au ft)
<br />6,2, PGI
<br />Cu Ft.
<br />UN3291 Regulated Medical Watte, n,o,s.,
<br />6,2, PGI
<br />Cu Ft.
<br />UN329i Regulated Medical Waste, n.o.s ,
<br />6.2, PGIj
<br />Cu Ft.
<br />3. Gonerator"a Cortlficatlon: °I hereby declare that the contents of this consignment are fully and accurately TOTALS ® v Cu Ft.
<br />c}es above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />a ospects In proper condition for trans d according to applicable International and national ernmental regulations"
<br />tPr to ad Name ig ure Date
<br />'
<br />PORTER 1 ADDRESS: Pho
<br />Stericycle, Inc. This is a Through shipment
<br />>-
<br />W
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave Hauler Reg# 3400
<br />FrennorCA 93722
<br />O
<br />TRANSPORT RTIF CA : Receipt of medical waste as describe
<br />PrinMpa Ndme _ Signature Date
<br />8,'INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #
<br />Applicable Permit Numbers:
<br />r'
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrjnMpe Ndmo Signature Date
<br />6.,INTERMEbIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />�+
<br />&
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />xx
<br />Prjn*Po Norge Signature Date
<br />7, DISCFIEPANOY INDICATION
<br />21 8A, Doslgnatad Facility: 88. Alternate Facility: Fj 8C. Alternate Facility: L] 8D. Alternate Facility:
<br />Ste cycle, Inc. d cle, Inc. Stedcycle, Inc. Covante Marlon,lnc
<br />4135 W. Switi AVO ti
<br />N.Paxboro Drive 1551 Shalton DM 4850 Brooldake Road NE
<br />Fresno, CA 93722 lorth Salt Lake, tri 84034 Holiistar, CA 95023 Brooks, OR 97305
<br />(566783.742plEAt�#NEa gg1)a38-it7a (ssB)783-i422 (S05)as3-a89Q
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<br />TS! 22 A04481JA-36 TSIOST 83 Parm t# 364
<br />a
<br />15 2010
<br />TREATMENT FAt;1LITY: i certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />I—
<br />received the abovo 12 01 AgArtes in accordance with the requirement outlined in that authorization.
<br />PrinVlype Name Signature Date
<br />nark Erre tea a herr, I CU ft to
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