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MEDICAL WASTE TRACKING FORM NUMBER
<br />`®4 etl'°icycle° CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424 STANDARD MANIFEST 001 -10 -06 -STD
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<br />a"+-- #:. 12. i - 20 CUSTOMER NO, 21132 MDFRO( JDCL
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MDICRL GEI TI;R
<br />1617 'N CALIYORMIA ST
<br />SWXXToN, CA 95204— 6117
<br />(209) 451-91031 3/28/2017
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<br />CUSTOMERNUMBER 6il1$52-001 GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBO5 — 40 Gal Tub (BiO) (5,3 Cut ft)
<br />CONTAINERS
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<br />6.2, PGII
<br />UN3291; Regulated Medical Waste, o.e.s.,
<br />TB — :37 t'.;al Tub (BiO (4.9 cu ft)
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<br />6.2, PGII
<br />Regulated Medical Waste,n.o,s.,
<br />TBl — 44 iatl Tub(nio) (5.9 Cu ft)
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<br />QUN3291,
<br />Regulated Medical Waste, n o
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste,n.o.s.,
<br />I 1— Bio) N►F3.1—(Path) WC31—(Cbemo)31 Gal Tub(4.340
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<br />UN3291 Regulated Medical Waste,n,o.s.,
<br />wB#3—(B.iu)jPGr43—(Path)fCW43—(Chemo) eel Tub(5.7CUFT)
<br />6.2, PGII
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />1SMB — Bi.io'sysr m. s Cattdboa rd Box (4.2 Cut ft)
<br />62, PGII
<br />Cu Ft
<br />UN3291,' Regulated Medical Waste, n.o,s.,
<br />Cu Ft.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Cu Ft
<br />6.2, PGII
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accu tely TOTALS ® t Cu Ft
<br />doscr ove by the proper shipping name, and are classified, packaged, marked and labelled/placar ed, d
<br />4in, all res ets in proper condition for transport according to applicable International and nail en tai regulations!
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<br />I printe yped Name�_1/?��`'v�� Ig
<br />ORTER 1 ADRW,,rCle,. Itle. ® This is a Thtou}h Sttipttt rct Phone #: —
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<br />4135 1'#. Swift ?Lve Applicable. ermitPegr# 3400
<br />�Ce�tsa,CA 93722
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<br />TRANSPORTER T[FI AT[ON: eceipt of medical waste as described
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<br />PdnUlype, Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TR NSPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print(Type Name _ Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #.
<br />o
<br />Applicable Permit Numbers.
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<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
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<br />Print/Type Name Stgnature Date
<br />7. CREPANCY INDICATION
<br />8A D d Facility: 86. Alternate Facility: 8C. Alternate Facility: ❑ 8D. Alternate Facility:
<br />Stelicycle, Inc. S rIcycle, Inc. Siedcycle, Inc.
<br />—' X413 90 M FObana Olive 1651 Shelton Dirt"
<br />a Fro; 40 North sett Lake. UT =64 Hollister, CA 95623
<br />783 id 2
<br />(Tra! 422
<br />Sk-448TWOS 93422
<br />8 2017
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<br />TREATMENT FA&ft-gertify 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 outiined in that authorization.
<br />PrinMpe Name Stgnature Date
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<br />c7R16INAL
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