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MEDICAL WASTE TRACKING FORM NUMBER <br />®® *O Stericy( le, CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424* STANDARD MANIFEST 001 -10.06 -STD <br />• ftwoingftW,.Rc "dA9Rr,k; CUSTOMER NO. 21132 <br />1. Generator's Name, Address and Telepti6ne`hium6er `� +" - <br />ATT[ : <br />GILL MEDICAL CZNTER <br />617 Irl CALIFORNIA ST <br />ST TON, CA 95204- 6117 <br />CUSTOMER NUMBER <br />2A. DESCRIPTION OF WAST .. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291 Regulated Medical Waste, n.o,s., <br />6.2, PGII TRI9 :37 Gal: Tl <br />® 6U232P9r�11+ Regulated Medical Waste, n.c.s., <br />4 6UN3229r�11� Regulated Medical Waste, o.o.s., Mal Cal: Tv <br />pC 1821- 1310) ITP15- <br />W : UN3291 Regulated Medical Waste, n.o.s., <br />LU 6.2, PGII _ <br />jgio) 1=31 <br />UN3291,-Regulated Medical Waste, n.o.s., <br />6.2, PGII wao <br />aR <br />UN3291, Regulated Medical Waste, n.o.s., ` ~'" <br />GENERATOR's REGISTRATION # <br />CONTAINERTYPE <br />UN3291 Regulated Medical Waste, n.os, <br />6.2, PGII <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and occur <br />describ Dove by the proper shipping name, and are classdied, packaged, marked and labelled/ ar <br />12N)n pects lit proper condition for transport according to applicable international and not' <br />TOTALS 11111, - <br />and and <br />2C. NO. OF 12D. VOLUME <br />CONTAINERS <br />Date , <br />SPORTER 1 ADDRESS:Phone #. r ' <br />Applicable Pe4r�tit'AtJu�tl R-'742-2 <br />>- ►- Sti�i:iev .1e, Inas. This is a; Through shipxae>xt Pp <br />2 as 4135 Q. Ssaitt Ave Hauler Reg# 0400 <br />Fre Intl Cp 93722 <br />a z¢ TRANSPORT RTIFICJ lV: Recet t of medical waste as describe ove <br />``' <br />Print/Type Name Signature Date <br />5. INTERMEDIATE Da� <br />t 2 RANSPORTER 2 ADDRESS: Phone #: <br />Applicable Permit Numbers. <br />. R V - <br />y INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printtrype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone #. <br />Applicable Permit Numbers - <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />15 - x Print/type Name Signature Date <br />7. D]SGREPANCY INDICATION <br />" <br />AGA. Designated FaCglty: U 88. Alternate Facility: tJ 8C.Altomate Facility: ❑ 81). Altemate Facility: <br />..i <br />i Steric ycle, tntz, ataricycle, Inc. ftrleycle, Inc. <br />1< 41315 W, "ITAYa 50 N. F>+XttAtU ativ� 15151 Sl�lt�rt Drive <br />Fr Atli {il1z North Salt Latte, UT 24054 Hollister, CA 95823 <br />($6-6)7M7422 ($$6)7M7422 <br />j 3A -448 -JA -36 TWOST 83 <br />Wx(97 <br />X TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F- received the aboX.ind ted wastes in accordance with the requirement outlined in that authorization. <br />PrinUType Name Signature Date <br />Transferred containers, cu R to <br />Q <br />ORIGINAL <br />Cu <br />Cu Ft. <br />