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Steric
<br />�`t,— - -- — MEDICAL WASTE TRACKING FORM NUMBER
<br />s4 a J i,G Yi�.�/CC® CgSE OF EMERGENCE` CCNTACT: CHEMTREC i-800 42 STANDARD MANIFEST 001 -10.06 -STD
<br />J
<br />Route #�: 123 - 2 L CUSTOMER NO, 211132 MDFROOKJMM
<br />nRIIGINA L
<br />1. Generator's Name, Address and Telephone Number
<br />1111111111111111111111111111111111111111111111111111111111A`CTri -.
<br />GILL MEDICAL CENTER
<br />161.7 14 CALIi'ORNIA ST
<br />S`aC."KT4Nr CA 95204- 11117
<br />(203} 451-9031
<br />5/812018
<br />CdSTCMER NuM9ER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3201 Regulated Medical Waste, n,o.s.,
<br />6.2, PGI
<br />rB04 - 28 [+al. Tub {B{3.7 cu ft)
<br />CONTAINERSio)
<br />Cu Ft.
<br />-1-
<br />UN32g1, Regulated Medical Waste, tl,o.s.,
<br />6,2, P611
<br />B - 37 C,at1 Tub {Bio) {4.9 cu ft)
<br />Cu Ft
<br />M
<br />Ci
<br />UN320f Regulated Medical Waste, n,o .,
<br />6,2, PGII
<br />!1.4 44 Cal Tub (Bio) (5-9 cu ft)
<br />✓
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />E — TP TY. — 1 u Gal Tu < CUF'T
<br />6,2, PGI(
<br />Cu Ft.
<br />tL I
<br />Z
<br />UN3291 Regulated Madle0l Waste, n.o.s.,
<br />6,2, PH
<br />Cu Ft.
<br />Lu
<br />L7
<br />UN3291 Regulated Medical Waste, n o s„
<br />6,2, PGfi
<br />1343 /WC43— { ) t3s1 Tub (5.7CUFT)
<br />Cu Ft,
<br />UN32gf Regulated Medical Waste,rr,a.s.,
<br />612, PGR
<br />Biosystems Cardboard Box (4.3 cu ft)
<br />Cu Ft,
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />62, PGII
<br />Cu Ft.
<br />UN3201 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 ' ALS �"
<br />,�
<br />Cu Ft,
<br />by tho proper shipping name, and are classified, packaged, marked and labelled/pl rdd, a
<br />spects in proper condition for transport according to appllicablle international and natio go m nt gula ions."d/iyped
<br />ndabove
<br />r "' '
<br />ate
<br />Name t� ign re
<br />a
<br />4,TRA ORTER 1 ADDRESS;�
<br />Steric cls IticLf This is a T ro Shipment
<br />"'� .
<br />Pho 9Vb
<br />Applicable Permit Numbers;
<br />4135 W. Swift Ave Hauler; Reg¢ 3400
<br />4 0
<br />E'remno, CA 93722
<br />a Q
<br />TRANSPORT RT[F AT . Receipt of medical waste as describ4ab
<br />ham-
<br />PrinVlypo Name Signature
<br />5. INTERMEDIATE HANDL /TRANSPORTER 2 ADDRESS;
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers;
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS;
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />lY
<br />Pr]nMps Name Signature
<br />Date
<br />7. DiSCREPANCY INDICATION
<br />tY4A,Q9skjrAtoc1 Facility: 813, Allemate Facility: ❑ 80. Altemate Facility:
<br />❑ BD.Altemate Facility:
<br />Stedcycle. inc. kericycle, Inc. Stericycle, Inc.
<br />Covanta Madon,lnc
<br />v =
<br />4136 W. Swift AVa 30 N. FOXboro Drlve 1551 Shelton Drive
<br />4860 Elrooklake Road NE
<br />lrr'esno CA 83722 Borth Salt Lake, Ur 84061 Hollister, CA 85023
<br />Brooks, OR 87305
<br />.,
<br />(866)7b3-7422 801)9315-1171 (866)783-7422
<br />(505)383-0890
<br />TSIOST-22 Dpt,>~A_1' eaffm A-4481JA-38 TSIOST89
<br />Perm1#384
<br />�
<br />1.
<br />TREATMENT KWLITVB1 24p that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />recelVed the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Prinfllypo Name Signature
<br />Date
<br />o
<br />nRIIGINA L
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