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iYo•® Stericycle®
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />SE OF EMERGENCY CONTACT: CHEMTREC 1-800-424_
<br />-800-424 STANDARD MANIFEST 001 -10 -06 -STD
<br />Ae #: 123 — 22 CUSTOMER NO. 21'1'5 140FR,OOKM
<br />ORIGINAL 1
<br />1. Generator's Name, Address and Telephone Number A'�'T�:III
<br />GILL MEDICAL CENTER
<br />1617 N CALIir ORNIA ST
<br />siroim TON, CA 95204- 6117
<br />(209) 451--9031 3/13/2018
<br />CuaTOMERNUMBER 6111852-001 GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Rsgufated Medica( Waste, n.o.s,,CONTAINERS
<br />6.2, PGII
<br />'C805 — 4t) Gal Tub (Bi a) (5.3 au ft)
<br />Cu Ft.
<br />UN3291Regulated Medical Waste n.o.s.,
<br />6.2, PGII
<br />TB4 _ 37 Gal Tub (Bio) (4.9 Cu ft)
<br />Cu Ft
<br />CC
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />B1 44 tial Tub (Bio) (5.9 Cu ft)
<br />®
<br />62, PGII
<br />Cu Ft
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB21-- (Blo) /TIe15» (Patin)/TY15-- (Chemo) 20 Gal Tub (2.7CUFT)
<br />6.2, PGII
<br />Cu Ft.
<br />UJ
<br />Regulated Medical Waste, n.o.s.,
<br />U2,
<br />WB31- (Bio)/WP31- (Patti) /WC31- (Chemo)33 Gal Tub (4.14CUPT)
<br />�
<br />6.2, PGII
<br />PGI
<br />Cu Ft.
<br />0
<br />6 2 PGII Regulated Medical Waste, n.o.s.,
<br />W243— (Bi.o) /Puua3- (Patin) /CK43— (Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291, Regulated Modtcal Waste, n.o.s.,
<br />6,2, PGII
<br />XRB; _ Biosystems Cardboard Sox (4.2 cu ft)
<br />Cu
<br />UN3291 Regulated Modica! Wants, n o s.,
<br />6,2, PGII
<br />Cu Ft,
<br />UN3291 Regulated Medica! Waste, n.o.s.,
<br />6,2, PGII
<br />Cu Ft
<br />3, Gan ator's Certification: °I hereby declare that the contents of this consignment are fully and accurately TOTALS ` ., Cu Ft.
<br />dos a above by the proper shipping game, and are classified, packaged, marked and labAlee, and
<br />in spects In proper condition for transport according to applicable international and nt a ulations°sPntad(iyped
<br />(�6 jate)—,-
<br />Name v ' , x
<br />14WN-SPORTER1 ADDRESS:Phone #: (86M83-7422
<br />Stericycle, Inc. ® Trois i.,a rough ahi.pmtent
<br />0
<br />Applicable Permit Numbers,
<br />4135 W. Swift Ave Hauler Reg# 3400
<br />N,
<br />Fre3no,CA 53722
<br />a
<br />TRANSPORTER rN: Recalledical waste as desc d abov
<br />9P—Data
<br />F-
<br />Ptint/lype Name Signature
<br />5. INTERMEDIA ND 2 /TRANSPORTER 2 ADDRESS. Phone #:
<br />5gApplicable
<br />Permit Numbers:
<br />y'@8
<br />n
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />g tc
<br />Applicable Permit Numbers:
<br />L
<br />y
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />Printrfypa Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />813.
<br />A. Doalgnalad Facility: [] 88. Altemate Facility: 8C. Attemato Facility: Alternate Facility:
<br />3
<br />cle. Inc. Stericycle, Inc. Stertcycle, Inc. Covanta Marlan,Inc
<br />34135
<br />W. SMftAV* 90 N. Foxboro Orto 1551 Shelton DrNa 4850 8rooklake Road NE
<br />L%
<br />Preeno CA 93722 North Salt Lake, LJT 84054 Hoillater, CA 96023 Brooks, OR 97305
<br />z
<br />(86616 43.7422 (801)93&117,1 (866)783-7422 (60511393.0690
<br />TSJOST-Au ORTIZ
<br />ow 3A44e1JA-86 IVOST 93 Permit* 364
<br />TREATMENTK61-N 1204Y that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Printfrype Name ' _ Signature Date
<br />ra S erre containers, on ft to
<br />ORIGINAL 1
<br />
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