|
MEDICAL. WASTE TRACKING FORM NUMBER
<br />p®id SterAC CIy e' VCASE OF EMERGENCY CONTACT: CHEMTREC 7.800-424- STANDARD MANIFEST 001 -10.06 -STD
<br />w • ProtwingPeopL,A, udngAlsk.' Route ,Oa i 23 1 CUSTOMER N0.2ii32 MDFROO.766L
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />pj
<br />GILL MEDICAL CL N I
<br />1517 N CALIZORWIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9131 5/9/2017
<br />CUSTOMER NUMBER 611"1852--0()1 GENERATOR'sREGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />20, CONTAINERTYPE
<br />2C. No. OF
<br />20. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s,,
<br />6.2, PGII
<br />TB05 — 40 Gal Tub (Bio) (5.3 cu 1~t)
<br />CONTAINERS
<br />Cu Ft.
<br />Regulated Medica[ Waste, n.os„
<br />UN3291, PGII
<br />6.2,
<br />, PGII
<br />T#J9,_ — 37 G43. Tub (Bio) (4 , 9 cu tt)
<br />Cu Ft.
<br />(')
<br />0
<br />UN3291 Regulated Medical Waste, n.o,s ,
<br />6.2, PGII
<br />TH1.4 44 Cal flub (Bio) (5.9 cut -Et)
<br />Cu Ft.
<br />82PGIjRegulated Medical Waste, n.o.s,
<br />_(Biq)iTP15-(paCh)lgyts_(Ch�yap)Zlp Gal Tub(2_7auF
<br />)
<br />Cu Ft
<br />W
<br />Z
<br />6.23291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />WB31--(Bio)/WP3.t-(Pdtt1)/GIC31-(C'hemo)31 Gal Tub(4,14C
<br />T)
<br />Cu Ft.
<br />LU
<br />UN3291 Regulated Medical Waste, n o.s„
<br />6.2,PGI1'
<br />wB43—(Bio)IEW43—(Path)/CW43--(Chemo) Gal Tub(5.7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />KRLB — Biosystems Cardboard Bax (4.2 cu £t)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste,
<br />8,2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n,o.s ,
<br />6.2, PGII
<br />Cu Ft
<br />3. Gen ator's Certification: "I hereby declare that the contents of this consignment ly and acc
<br />rately TOTALS ® Cu Ft.
<br />describe above by the proper shipping name, and are classified, packaged, marked c
<br />rded, andare
<br />:anddlabelledipja
<br />In all aspects in proper condition for transport according to applicable internationn onal g
<br />`
<br />vernmenta ations °
<br />r
<br />`
<br />1 Prl iedfryped Name n_[ atu
<br />at
<br />4.TRAN ORTER 1 ADDRESS: Phone #: E-yS) 783-7422
<br />w
<br />St:ecieycle, 1110. Thts s Through 3hxpman Applicable Permit Numbers:
<br />a
<br />4135 A. swift Ave Hauler Reg# 3400
<br />o.
<br />E'cesna,CA 93722
<br />o� Q
<br />r
<br />TRANSPORIZRCEPITIFICATI ceipt mad, I waste as described ab
<br />Printlfypa Name Signature Data
<br />S. INTERMEDIATE HANDL R / TIZIAINISPORTER 2 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />o�
<br />a�
<br />in
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature Date
<br />e%s
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS, PhoneCc #:
<br />Numbers:
<br />Applicable Permit
<br />w
<br />y
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above
<br />x
<br />—
<br />Print/Typo Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />}si
<br />natod Facility: 8B. Alternate Facility: 8C. Alternate Facility: BD. Alternate Facility:
<br />J
<br />U lCy/cle. Inc.'I _ Uflcyd e. Inc. Start e. Inc.
<br />- SO N, FOAM OrNe 1651 Sh4 t� ®rt"
<br />Q
<br />LL
<br />AW -Nell
<br />Fresn4.CA SN22 North Salt Laka, UT 84054 iiaUkftt; CA 95023
<br />z
<br />(865)783.7422 (8783-7422 (88783-7422
<br />Lu
<br />TiNST22) 2917 a4448 -JA -S6 TSMT 83
<br />W
<br />TREATMENT*A'GIW*,-:f certify that t 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 />Printlrype Name Signature Date
<br />Tra ed coldafntm, cu tt to '
<br />ORIGINAL
<br />
|