|
_ -- I — �— — MEDICAL, WASTE TRACKING FORM NUMBER
<br />teriC de! ASE of EMERGENCY CONTACT: CHEMTREC 1.600«42 STANDARD MANIFEST 001 -10 -o6 -STD
<br />1coute 0: 123 – 22 CUSTOMER NO. 21132 MDFRC3OMW
<br />_
<br />1. Generator's Name, Address and Telephone Number
<br />1111111111111111111111111111111111111111111111111111AWN :
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />smCKI`ON, GA 95204— 6117
<br />(209) 451-9031
<br />3/27/2018
<br />CUSTOMER NuMeER 61-11852-001 GENERATOR'S RrmISTRATieN #
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Madlcal Waste, n.o.s.,
<br />6.2, PGI 9
<br />T$i)9 – 28 tial Tub (Bio) {3.7 en ft}
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />TB49 – 37 Gal Tuft (Bio) (4.9 cu ft)
<br />62, PGI1
<br />Cu Ft.
<br />Regulated Medical Waste, n.o.s.,
<br />Hr – 44 Gal. Tub (;bio) (5.9 cu ft)
<br />it
<br />6,23291,
<br />foo Cu Ft.
<br />Q
<br />UN3291 Regulated Medical Waste, n.c,s„
<br />Til – TE – Tx – GalT CUFT
<br />fg
<br />6.2, 13611
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste, n,o.s„
<br />Z
<br />6.2, PGiI
<br />Cu Ft
<br />uj
<br />UN3291 Regulated Medicai Waste, n.o.s.,
<br />{ } /tdCd3— { } [Lal Tub {5.7GU>?T}
<br />6.21 Pail
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGI
<br />KR — Biosystems Cardboard Bax (+4.3 cu ft)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGiI
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o,s.,
<br />6.2, PGII
<br />Cu Ft
<br />S. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS �
<br />.. Cu Ft.
<br />de hove by the proper shipping name, and are classified, packaged, marked and labelled ed, an
<br />es acts in proper condition for transport according to applicable international and na nal o me al gulation
<br />I t
<br />9127
<br />Printed pad Name SI to
<br />ate
<br />4. TRANSP TER 1 ADDRESS; e --s
<br />�tEs1 � ,G� L,, ItZC. This is a Through shipment
<br />Phone #: ,i–
<br />Permit
<br />Lu"
<br />a
<br />,Li
<br />4135 V. Swift Ave
<br />Apprycabfe Numbers:
<br />Hauler Reg{/ 3400
<br />Ca
<br />Frecno,CA 93722
<br />n8.
<br />TRANSPORTS IFIL : ecelpt of medical waste as described a vs.
<br />Print/Type Name Signature
<br />2
<br />Date 7
<br />5. INTERMEDIATE HANDLER 2 /JAANSPORTER 2 ADDRESS:
<br />Phone #:
<br />RUApplicable
<br />Permit Numbers:
<br />IO
<br />2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />I
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />rccc
<br />e
<br />Applicable Permit Numbers:
<br />ow
<br />z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />c
<br />fE
<br />Printliype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />f
<br />a Hated Facility; ❑ 80, Alternate Facility: E] 8C. Alternate Facility:
<br />❑ BD. Alternate Facility:
<br />i
<br />Stedayale, Ina. S rIcycie, Ina. Stericycle, Ina.
<br />Coventa Madon,ina
<br />ES
<br />4135 W, Svu(ftAve 80 N. Foxboro Dave 1551 Shelton Drive
<br />4850 Brooklake Road NE
<br />uu._
<br />Fresno CA 93722 Noah Sa)t lake, UT 84054 Hollister, CA 55023
<br />Brooks, OR 97306
<br />(866)763-7422 (801)936-1171 (866)783-7422
<br />(505)383.0850
<br />TS/OST-22 3A-448MA-36 TSIOST 83
<br />PerM)t# 364
<br />a
<br />DALg ANNU Offit
<br />.
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />t~
<br />received the Indicated�Hrwastes in accordance with the requirement outlined In that authorization.
<br />Mabove
<br />AR 27 �
<br />Print/Type Nate Signature
<br />Date
<br />ran& errs containers, cu III to.,.
<br />
|