|
MEDICAL WASTE TRACKING FORM NUMBER i
<br />Q"Q 5tericycle° CASE OP EMERGENCY CONTACT: CHEMTREC 1-800-424-9 0 STANDARD MANIFEST 001 -10.06 -STD
<br />• P$010ninghOPI&RedaIng1111V Route 0e lis — 17 CUSTOMER NO. 21132 MDER0013 C
<br />1. Generator's Name, Address and Telephone Number
<br />ATTU:
<br />GILL MD1CAL CENTER
<br />1.6'17 r3 f ALIFORWIA ST
<br />SAN, CA 95204- 61.17
<br />451•-9031
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION III
<br />2A, DESCRIPTION OF WASTE 2B. CONTAINER TYPE
<br />6 23PGII Regulated Media! Waste, n,o s., IROS — 40 Gal Txxb (Bi0 (5.3 cu ft)
<br />6.2, PGII Regulated Medial Waste, n,c.s., TB49 _ 37 fAl ftb (Bio) (4,9 au tt)
<br />M
<br />6 23PGII Regulated Medical Waste, n o.s., B�4 _ 44 Gal `ub (B oli (5.9 cu ft)
<br />UN3291. Regulated Medical Waste, n.o.s., ,t_ Pard) J 'P15— (path) IT3t15— (Cheroo) 20 teal Tub (2.7CUF
<br />6.2, PGII
<br />W UN3291, Regulated Medical Waste, n.o.s.,
<br />W 6.2, PGII 111131•-(Ri.b)IW31—(Path)MU31—(CIaemo)31 Gal Tub(4.14CU
<br />623PGIlRegulatedMedicalWaste,n.o.s., Gal TublS.?cuFT)
<br />UN3291, Regulated Medical Waste, mo s,
<br />6.2, PGII nEt — Biosystems Cardboard Box (4.2 cu ft)
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />6.2, PGII
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />62, PGIJ
<br />3. Gane ator's Certification: "I hereby declare that the contents of this consignment are fully and accu2tel T®TALS /'
<br />des be above by the proper shipping name, and are classified, packaged, marked and labelled! rite and
<br />In aspects In proper condition forstetrtsport according to applicable International and na - al o er enguiations."
<br />1.8/2€317
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />Ft.
<br />ilm
<br />cc -21-1RAMSPORTER 1 ADDRESS: if Phone #: (T 6) 783-7422
<br />W Stericyc1e, Inc. ® 'this s ie a Wcough 1311PI ant Applicable Permit Numbers:
<br />tz 4135 W. Swift Ave
<br />a o Bauder Reg# 3400
<br />0. Ecesno,CA 93,722
<br />na. a TRANSPORT TiFI TI ace decal waste as described abo
<br />F-
<br />~ Print/Type Name Signature Date
<br />5. INTERMEDIATE MDRER72 /TRANSPORTER 2 ADDRESS: Phone #:
<br />NnN,y g
<br />. Applicable Permit Numbers'
<br />oLUo
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrinVType Nanta Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />Applicable Permit Numbers,
<br />a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 1
<br />ax�r
<br />— Print/T•ype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />w
<br />tt'?
<br />gngted Facility: I ❑ 88. Altemate Facility: ❑ 8C. Attemate Facility: ❑ 8D. Alternate Facility:
<br />sbarlayale. Inc.
<br />7fde, trta. SWayate, Inc.
<br />4� 90 N. FC40M DMD 1551 Sfi bill Drive
<br />(888j783 -?422 NIDdh S8 k Lake, Ur 8 54 Hdltisbr; GA SM23
<br />'RIM
<br />�� Q88Sj783-?422 (783 -?d22
<br />3k448 -.A-36 I T Ski 83
<br />TREATMENT" Aa1tm certify 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 />Print/rype Name Signature Date
<br />.#,a.., _, a 1 :,
<br />ORIGINAL
<br />
|