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MEDICAL WASTE TRACKING FORM NUMBER
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<br />O • ® SSE riC�/CN@ N CASE OF EMERGENCY CONTACT: CHEMTREC 1-8Of?-424- 0 STANDARD MANIFEST 001 -10.06 -STD
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<br />1. Generator's Name, Address and Telephone Number
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<br />GILL 14EDICAL CE14TER
<br />11617 N CALIT.OR141A ST
<br />S'1O MM11, CA 95204- 6117
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<br />4/25/2017
<br />CUSTOMI:RNUMBER 61.1.:1.8.52-0p"„ GENERATOR'S REGISTRATION If
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN36 2, PGII 91Regulated Medical Waste, n.o.s.,
<br />TB05 — 40 Gal Tufa (Bio) (5.3 Cut 1:it)
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<br />62, PGI� Regulated Medical Waste, n as.,
<br />TB49 — 37 Gal Tub (Bio) (4.9 du it)
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />fiH — i4 Gal Tub(Rif,e) (5.9 cu tt)
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<br />UUN32P991, Regulated Medical Waste, n.o.s.,
<br />T]32— (B.TO) /TPIS-- (Fath)/TY15-� (Chemo)20 Gal Tub (2-7CUF
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<br />UN3291, Regulated Medical Waste, It o.s.,
<br />62, PGII
<br />Gal Tub(4.14CU T)
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<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2,PGII
<br />NE43—(Bio)/Fw43- (pit th)/Cr43--(C,heina) Gal Tub(5.7CUF'T)
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<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2, PGII
<br />XRB -- Ellosystems Cardboard Box (4-2 au ft.)
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and ac rately TOTALS ®
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<br />de ' d above by the proper shipping name, and are classified, packaged, marked and labelled car ed, an
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<br />a e i spects in proper ondition for transport according to apple able international and net a o m air lafions"
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<br />4.TRAN ORTER 1 ADDRESS:
<br />Stenicyu le, This is a Through ShipMI.Int
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<br />Phone #: (36) 78-7422
<br />Applicable Permit Numbers:
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<br />Inc.
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<br />4135 W. Swift Ave
<br />fir✓*q# 34110
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<br />QTRANSPORTS
<br />Fzesitio,CA 93722Hauler
<br />JETIFI?ATIO ipt of me at waste as described ab
<br />Print/Type Name Signature
<br />Date
<br />S. INTERMEDIATE NDLER 2 /ITRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers.
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<br />02.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medfcaf waste as described above.
<br />Date
<br />Print/rype Name Signature
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS;
<br />Phone #.
<br />Numbers,
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<br />Applicable Permit
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Prfnt/Type Name Signature — —
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />A. Designated Facility: 86. Alternate Facility: ❑ aC. Alternate Facttity.
<br />8D. Alternate Facility:
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<br />a" tericycle. Inc. tricycle, Inc- Sberieycle, Inc.
<br />41 SSW, Shunt Ave 90 N. Foxboro DrWe 115 1 Shaiitan Drive
<br />Fres&fiAk 3P...@ffn,- North Salt Lake, LIT 84054 Hollister, CA 96023
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<br />(866)783-7422 (869)7M7422 {8t2"i )783-7422
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<br />TREATMENT FAiILertify that I have been authorized by the applicable state agency to accept untreated
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<br />medical wastes and that f have
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<br />received the , wastes accordance with the requirement outlined that authorization.
<br />Print/Type Name Signature
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<br />Date
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