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MEDICAL WASTE TRACKING FORM NUMBER
<br />asp terricycle'#ASE OF EMERGENCY CONTACT: CHEMTREC 1 80042 STANDARD MANIFEST 001 -10.06 -STD
<br />te #: 123 — 16 CUSTOMER NO. 21132 MDFROOKEWY
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<br />1. Generator's Name, Address and Telephone Number
<br />A`PTN
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STtxmow, CA 95204-- 6117
<br />CusToMERNuMBER 6111852-001
<br />(209) 451-9U31
<br />GENERATOR'S REGISTRATION #
<br />4/3/2018
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />20. NO. OF
<br />21). VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T804 - 28 [tai Tub (Bio) (2-7 cu ft)
<br />CONTAINERS
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: described
<br />6.2, PGIf
<br />Receipt of medical waste as above.
<br />Cu Ft.
<br />6 2, PGII Regulated Medical Waste, n.a.s.,
<br />T _ 37 Gal Tub (Bio) (9.9 cu 1:t)
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone M
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<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />Bl4 44 Gal Tub(Bio) 0} {5.9 Cu f t}
<br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printr ypo Name Signature
<br />Date
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<br />6 N3 91 Regulated Medical Waste, n.o.s.,
<br />x&i- ( ) /Tpgg- ( ) /Tyl5'" { ) 2d [dal Tub (2.7CUPT)
<br />8A. Designated Facility ® 8B. Alt -mate Facility: [] 8C. Alternate Facility:
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<br />UN3291 Regulated Medical Waste,
<br />6.2, PGII
<br />Inc. Stedcycle, Inc. Stedicle, Inc.
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<br />Covente Marlon,lnc
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<br />4135 W, Swim Ave 90 N. Drlue 1551 helton Drive
<br />4656 Brooklake Road NE
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<br />UN3291 Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />W843-- ( ) /WP43- ( ) /W043- ( } tial Tub (5.7CWT)
<br />(866)783-7422 (801)936-1171 (866)788-7422
<br />(5051l898-0890
<br />TS/OST-22 3A-4481JA-36 . TS/0ST=83
<br />Permit # 384
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KR - Biosystems Cardboard Box (4.3 cu ft)
<br />aTREATMENT
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />received the In IVisal stes In accordance with the requirement outlined in that authorization.
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<br />PrinMpe Name Signature
<br />Date
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<br />UN3291 Regulated Medical Waste, n,o.s„
<br />6,2, PGII
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<br />3. Gonorator's Certification: "i hereby declare that the contents of this consignment are fully and accurately
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<br />T®TALS ►
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<br />�1�1(lrespects in proper cotld€tion for transport according to applicalye International and natio et-0over end
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<br />N TRANSPOF31
<br />PrinMpe Name
<br />d Name '—%I t r ry aVF
<br />1 ADDRESS:
<br />Stecicyale, I11C. This is a Through shipment
<br />4135 V. Swift: Ave
<br />irreanc,CA 93722
<br />iGERTIVICATIQN: Receipt of medical waste as describeda eve
<br />Signature
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<br />Phone #:
<br />Applicable Permit Numbers:
<br />E.aul.ec Reg# 3400
<br />Date q -3:(r
<br />5. INTERMEDIATE NDLER 2/TRAN5PORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />N�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: described
<br />Receipt of medical waste as above.
<br />Pdnl/rype Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone M
<br />� tx
<br />u@!j
<br />Applicable Permit Numbers
<br />A �� INTERMEDIATE
<br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printr ypo Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility ® 8B. Alt -mate Facility: [] 8C. Alternate Facility:
<br />E] BD. Alternate Facility:
<br />-tT'Meftyela,
<br />Inc. Stedcycle, Inc. Stedicle, Inc.
<br />cb=
<br />Covente Marlon,lnc
<br />sa
<br />4135 W, Swim Ave 90 N. Drlue 1551 helton Drive
<br />4656 Brooklake Road NE
<br />Fresno, CA 88722 North Salt Lake, UT 84054 Hollister, CAA 95023
<br />Brooke, OR 97305
<br />(866)783-7422 (801)936-1171 (866)788-7422
<br />(5051l898-0890
<br />TS/OST-22 3A-4481JA-36 . TS/0ST=83
<br />Permit # 384
<br />DAW. WNE Oi dClZ
<br />aTREATMENT
<br />FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />h-
<br />received the In IVisal stes In accordance with the requirement outlined in that authorization.
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<br />PrinMpe Name Signature
<br />Date
<br />--containers, CU 1t to
<br />G? A""aetv Transferred
<br />
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