|
MEDICAL WASTE TRACKING FORM NUMBER
<br />1®® i cle RGENCY CONTACT: CHEMTREC 1.800-424- STANDARD MANIFEST 001 -10.06 -STD
<br />*o' er#AS.EC;EME
<br />23 17 CUSTOMER No. 21132 MDFROOKB3S
<br />ORIGINAL_ _ . ..
<br />1: Generator's Name, Address and Telephone Number
<br />AWN:
<br />GILL MEDICAL CERTER
<br />16.7 N CALIFORNIA ST
<br />sTOCKT071, GA 95204-- 6117
<br />(209) 451-9031
<br />3/6/21718
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28• CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />T1305 _ 40 Csai �� (87i.4) (,5 - S Cu ��}
<br />CONTAINERS
<br />6.2, PGI!
<br />Cu Ft
<br />6 2329 Regulated Medical Waste, n.o.s.,
<br />TB49 - 37 Gal Tula (BiO (4.9 cu ft)
<br />Cu Ft
<br />DC
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />44 G&1 Tub (Bio) (5.9 ,'u fit)
<br />®
<br />6.2, PGII
<br />142
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.e.s.,
<br />Ts21- (sit]) /T1315—(Path) TY15- (CheRlo) 20 Gal Tttb (2.7cUFT)
<br />CII:6
<br />2, PGII
<br />Cu Ft
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, 1`1311
<br />WB31- (Dlty} /WP33.-• (Pat3l) /WC31- (Chean*) 31 Gal Tub (4.14CUFT
<br />Cu Ft.
<br />fZ
<br />UN3291 Regulated Medical Waste, n.o.s.lids43_(Baa)fpkX43-(Fath}/CW113-(cherao)
<br />6 2, PGI)
<br />Gal Tub(5.7cuPT)
<br />Cu Ft.
<br />U2, PGII Regulated Medical Waste, n.o.s,
<br />6.2, PG1!
<br />KRB _ Biosystems Cardboard Box (4, 2 cu fit)
<br />Cu Ft.
<br />UN3291 Regulaled,AAedical Waste, mo,s.,
<br />6.2, PGH
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6 2, 1`63I1
<br />Cu Ft.
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS
<br />descrlbed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />cls In proper condition for transport according to applicable International and natio
<br />Lmmepnlqulations"
<br />_t
<br />�Pr
<br />j
<br />�~
<br />to yped Name Sig tore
<br />-
<br />4.'rmKsPORTER 1 ADDRESS:
<br />Stecicycle, Inc. Th3-3 is a Through. shipment
<br />Phone #: (8 3-7.422
<br />4135 W. Swift: Ave
<br />Applicable Permit Numbers:
<br />a oHassler
<br />Frersna, CA 937.22
<br />ileal# 3400
<br />0.
<br />Uf
<br />a
<br />TRANSPORTS RTIFICA [O ical waste as clesc
<br />y
<br />mSlanaturn
<br />�-
<br />Frint(rype Name
<br />Date
<br />5. INTERMEDIA b 2 / RANSPORTER 2 ADDRESS:
<br />Phone #:
<br />HWApplicable
<br />Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />H ¢ �
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />31�=
<br />-
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />�j.
<br />eA, Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: ® 8D. Alternate Facility:
<br />le. Inc. 'uteri Cls, Inc. Sterlcycle, Inc.
<br />Covanta Marion,lnc
<br />u
<br />4136 W, SwlftAvib 90 N. Foxboro Drive 1551 Shelton Drive
<br />4650 Brooldake Road NE
<br />U<...
<br />Fresno, CA 83722 North Salt Lake, UT 84854 Hollister, CA 95023
<br />Brooks. OR 97305
<br />Z
<br />(866)783-7422 (801)938-1171 (8116)783-7422
<br />(50613MOSSO
<br />TSIOST 22 W.&WE ORT� 3A 4I8]JA 36 TSIOST 83
<br />Permit A 304
<br />Q'
<br />TREATMENT FA rt(� t l have been authorized b thea licable state agency to accept untreated medical wastes and that I have
<br />h
<br />received the abov8iii`dicai"ed W�' in accordance with the requirement outlined in�that authorization.
<br />PrlhVrype Name Signature
<br />Date
<br />10
<br />-Transforrad containers, Cil R to
<br />ORIGINAL_ _ . ..
<br />
|