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j MEDICAL WASTE TRACKING FORM NUMBER - <br />i ®p tericyi le OF EMERGENCY CONTACT: CHEMTREC 1-880 A2Q STANDARD MANIFEST 001 -10 -0e -STD <br />fAtSE <br />ua #: 123 4 CUSTOMER NO, 21132 MDFROOKDOR <br />1. Generator's Name, Address and Telephone Number <br />Al}�AN <br />GILL MEDICAL CENTER <br />161.7 N CALIP'ORNIA 5T <br />" STOCI(TDN, CA 95204- 6117 <br />(209) 451-9031 <br />CusTomER NumeER (5111852-001 GENERATOR'S REGISTRATION # <br />3/20/2018 <br />2A. DESCRIPTION OF WASTE 2E. ' CONTAINERTYPE 2C. NO. OF 121). VOLUME <br />2. PG[I Regulated Medical Waste, n.aCONTAINERS <br />6 s., TBO5 - 40 Gal Tub (V*o) (5.3 cu ft) Cu Ft. <br />6.2, PG <br />UN3291, Ropulated Medical Waste, mo s..1 TB 4 - 37 Gal Tub (Bio) {4 9 cu tt) <br />1= <br />1= <br />UNUZUT K0961 ate0 Medical Waste, <br />PGII <br />06.2. <br />Q <br />UN3201 Regulated Medical Waste, <br />6.2, PGII <br />W <br />Z <br />UN3291 Rapulaled Medical Waste, <br />6.2, PGII <br />C� <br />UN3291 Regulated Medical Waste, <br />6,2, PGII <br />n,o.s, Bl - 44 Gal Tub(Bio) (5.9 cta tt) <br />n.o.s., Ta 1- (1310) /TF15- (Fath)/T7r15- (Chemo) 20 Gal Tub (2.7CUFT) <br />Regulated ModIcal Waste, o.o.s„ <br />Ropulated Medical Waste, n,o.s„ <br />WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14GC <br />WB43-(Bio)/PW43-(Path)/CW43-(chemo) tial Tub(5.7cU>•T) <br />M - Biosystems cardboard Box (4.2 cu Et) <br />UN3291 Ropulatod Medical Waste, n.O.S„ <br />6.2, PGI <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and <br />de pOve by the proper shipping name, and are classified, packaged„marked and labelled <br />e In all re acts In pro er condition or transport according to apphc le International and nation <br />$rl d/iyped Na <br />4. SPORTER 1 ADDRESS: <br />SteriCycle, Inc. This is a <br />41.35 W. Swift Ave <br />m 0. Fresno,CA 93722 <br />IL d TRANSPORTE_k=TIFPATj0tq Receipt of medical waste as descnb a <br />Z,� <br />PrinUtype Name _ <br />S. INTERMEDIATE <br />TOTALS 1110- <br />Phone#: (866T,7193-7422 <br />Shipment Applicable Permit Numbers: <br />Hauler Reg#} 3400 <br />n.§- 3_7�O_t "r-_ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print/Type Name Signature <br />M 6. INTERMEDIATE HAtgDLER 3 / TRANSPORTER 3 ADDRESS: <br />a CJ <br />w CJ <br />ccINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />o: <br />— PrinVTypO Name Signature <br />C <br />2!�I pated Facility: <br />Stedaycle, Inc, <br />4135 W, SMAve <br />Fresno, CA 93722 <br />(866)793-7422 AKNE aim <br />TS/OST �-- <br />88. Attornato Facility: <br />Stericycle, Inc. <br />80 N. Foxboro Drive <br />North Salt Lake, UT 84054 <br />(801)936-1171 <br />3A -4484)A-36 <br />8C. Alternate Facility: <br />Sterlcycle, inc, <br />1561 shobn Drive <br />Hollister, CA 95023 <br />(866)7$3-7422 <br />TS/OST 83 <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />80. Alternate Facility: <br />Covante Marion,inc <br />4650 Brookiake Road NE <br />Brooks, OR 97305 <br />(505)393-0820 <br />Permit# 364 <br />TREATMENT FMARAQ c?018 that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicate wastes in accordance with the requirement outlined In that authorization. <br />Print/Typo Name 'aAQ**4 Signature Date <br />CU 11 to: <br />