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MEDICAL WASTE TRACKING FORM NUMBERi
<br />ASE OF EMERGENCY CONTACT: CyEMTREC 1-800.424 STANDARD MANIFEST 001 -0 -06 -STD
<br />Route #: 123 — 19 CUSTOMER NO. 21132 MDFROOKHR6
<br />1, Generator'$ Name, Address and Telephone Number
<br />ATTU :
<br />GILL MEDICAL CLr'N=
<br />1611 N MLXLrCRNEA ST
<br />STOCXTON, CA 9520E4- 6117
<br />CLImmm NumilEn 6111
<br />Medical Waste,
<br />Medial Waste,
<br />9) 451-9031
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />TBD4 — 28 Gal. Tub (Bio) (3_7 Cu 'fit)
<br />TB49 — 37 Gal Tub (Rio) (4.9 cu it)
<br />Bio — 44 Gal Tub (Bio) (5.9 cu it)
<br />TB21.-()/TP15-()/TY25-( )2d Gal Tub(2.7
<br />- Bio
<br />( ) tial
<br />Box (4.3 Cu
<br />3. Gonorator's'Cortifieation, "1 hereby declare that the contents of this consignment are fully and
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled
<br />respects In proper
<br />'condition for transJrtaccording to applicable International and na/tiio
<br />` , tR[t%n/ttttNanm%cy I lMrd'it�
<br />1 ADDRESS:
<br />stericycle, Inc.
<br />4135'11. Swift: Ave
<br />Frei�no,CA 93722
<br />medical waste as
<br />2/TRANSPORTER 2 ADDRESS:
<br />TOTALS 0 -
<br />and and
<br />D This is a Through shipment
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinmpe Name Signature
<br />4/24/2018
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />enone#: (86T783-7422
<br />Applicable) Permit Numbers:
<br />Hauler Reg# 3400
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />q 8. INTERMEDIA'T'E HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />ga Applicable Permit Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />x
<br />- PrinMpe Name - Signature Date
<br />7, DISCREPANCY INDICATION
<br />Deaignated Facility nB, Altematp Facility: aC.Alternate Facility: BD. Alternate Facility:
<br />-, Sieticyt:le,ltic. Sterlcycta, Inc. atericycta, int:. Cavafria Merion,tnc
<br />4135 W. UR AV* 90 N. Foxboro Drlw 1551 Shelton Drive 4850 Brooklake Road NE
<br />Fresno, CA 99722 North Salt Lake, LIT 84064 Hollister, CA 95023 Brooke, OR 97305
<br />(866)783-1422 (801)936-t-171 (8613)783-7422 (506)393-0880
<br />W TSIOST-22 3A 448/,A-38 TSIOST 83 Permit* 384
<br />F- -
<br />TREATMENT VACILITY: Iertl that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abavAicoi "s in accordance -with tf)e requirement} outlined in that authorization.
<br />M1s•
<br />PdriMpe Name Signature Date
<br />containers, all ;3 to
<br />2A. DESCRIPTION OF WASTE
<br />UN3291 Regulalod htedlcal Waste, n
<br />6.2, PGI1
<br />UN3291 Regulated Medical Waste, n
<br />6,2, PGII
<br />it
<br />UN3291, Regulated Medical waste, n
<br />62, PGII
<br />p
<br />Q
<br />UN3291 Regulated Medical waste, n
<br />6,2, PGII
<br />cc
<br />UJ
<br />=291, Regulated Medical Waste, n.
<br />Z
<br />6,2, PGII
<br />W
<br />a
<br />UN3291 Reoulatod Medical Waste, It
<br />'` 9) oniT
<br />Medical Waste,
<br />Medial Waste,
<br />9) 451-9031
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />TBD4 — 28 Gal. Tub (Bio) (3_7 Cu 'fit)
<br />TB49 — 37 Gal Tub (Rio) (4.9 cu it)
<br />Bio — 44 Gal Tub (Bio) (5.9 cu it)
<br />TB21.-()/TP15-()/TY25-( )2d Gal Tub(2.7
<br />- Bio
<br />( ) tial
<br />Box (4.3 Cu
<br />3. Gonorator's'Cortifieation, "1 hereby declare that the contents of this consignment are fully and
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled
<br />respects In proper
<br />'condition for transJrtaccording to applicable International and na/tiio
<br />` , tR[t%n/ttttNanm%cy I lMrd'it�
<br />1 ADDRESS:
<br />stericycle, Inc.
<br />4135'11. Swift: Ave
<br />Frei�no,CA 93722
<br />medical waste as
<br />2/TRANSPORTER 2 ADDRESS:
<br />TOTALS 0 -
<br />and and
<br />D This is a Through shipment
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Prinmpe Name Signature
<br />4/24/2018
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />enone#: (86T783-7422
<br />Applicable) Permit Numbers:
<br />Hauler Reg# 3400
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />q 8. INTERMEDIA'T'E HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />ga Applicable Permit Numbers
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />x
<br />- PrinMpe Name - Signature Date
<br />7, DISCREPANCY INDICATION
<br />Deaignated Facility nB, Altematp Facility: aC.Alternate Facility: BD. Alternate Facility:
<br />-, Sieticyt:le,ltic. Sterlcycta, Inc. atericycta, int:. Cavafria Merion,tnc
<br />4135 W. UR AV* 90 N. Foxboro Drlw 1551 Shelton Drive 4850 Brooklake Road NE
<br />Fresno, CA 99722 North Salt Lake, LIT 84064 Hollister, CA 95023 Brooke, OR 97305
<br />(866)783-1422 (801)936-t-171 (8613)783-7422 (506)393-0880
<br />W TSIOST-22 3A 448/,A-38 TSIOST 83 Permit* 384
<br />F- -
<br />TREATMENT VACILITY: Iertl that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abavAicoi "s in accordance -with tf)e requirement} outlined in that authorization.
<br />M1s•
<br />PdriMpe Name Signature Date
<br />containers, all ;3 to
<br />
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