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e <br />S�ericycle° <br />Protecting People. Reducing Risk' <br />MEDICAL WASTE TRACKING FORM NUMBER <br />kc <br />SE OF EMERGENCY CONTACT: CHEMTREC 1-800424 STANDARD MANIFEST 001 -10 -o6 -STD <br />ut a 12 i — 15 2 H F' ( ,77 <br />CUSTOMER N0.2113 _ jf�_ � ,,1(� „ , QX <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL 2MICAll C -'INTER <br />1617 11 CALIFORNIA ST <br />STOCKTON, CA 95204- 6117 <br />RI Ililllllhl�lllllll�llllllu�lll�l�91 <br />(209) 451-9031 <br />CUSTOMER NUMBER 6-1-11852-001 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE <br />UN3291, Regulated Medical Waste, n.o.s , TB05 — 40 Gal Tub (Bio) 1;5.:3 cu ft) <br />6,2, PGII <br />UN3291, Regulated Medical Waste, n o s,37 tj 37 Gal Tub (Bio) (4.9 au ft' <br />6.2, PGII <br />® 6,2UN3291 Regulated Medical Waste, n.o.s., 3,4 44 Coal Tub (Bio) (5.9 cu ft) <br />Q UN3291, Regulated Medical Waste, n.o.s., TB' - BIQ TP - Pa Tr - tta eruct 20 Leal flub (2. <br />M 6.2, PGII <br />LU UN3291, <br />1Z 6.2, PGII <br />�e <br />UN3291, <br />i <br />Q <br />g <br />a <br />Waste, <br />5/16/2017 <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />nos., WB31.-(Ril.o)/WP31-(Path}/WC31-4cli rno)31 Gal Tub(4.14C T) <br />n O.S., WB43- (Bio) /PH43- (Fath) /Cw43- (chemo) tial Tub (5.71DU T) <br />n.o.s., IMB— - Biosystems Cairdboard Bax (4.2 cu ft) <br />or's Certification: "I hereby declare that the contents of this consignment ars fully ae telt' T®7AL S 00.5e bove by the proper shipping name, and are classified, packaged, marked and Is / aca ed, a <br />all specis 1n proper condition for transport according to apypliclabley}' temational an na on r ntaE regu Irons" <br />r tedityped Name GF/• '�' ` n <br />PORTER 1 ADDRESS: <br />St:Geic yc le, It1.a. Q This Through shapmexxt <br />4135 W. swift: Atte <br />Freuno,CA 93722 : <br />SPOR CE TIFI . I - : 11 t edical waste as describ <br />ao Namp Signature <br />S. INTERMEDIA1'E'RA' of ER 2 /il'CANSPORTER 2 A13MI�ESS. <br />N t.✓ <br />�Q� <br />2U N INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />H. <br />PPrtntfrype Name Signature <br />Phone #: (866) 783-7422 <br />Applicable Permit Numbers - <br />Hauler Reg# 34.00 <br />. ✓ .✓� <br />Date <br />Phone # <br />Applicable Permit Numbers <br />Date <br />a 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS' Phone #: <br />Applicable Permit Numbers, <br />N Lo 2 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />We.,. <br />IE Print/Type Name Signature Date <br />1 17. DISCREPANCY INDICATION <br />v <br />z <br />w <br />a <br />Lu <br />cc <br />CV <br />r- <br />oslgnated Facility: <br />U 8B. Alternate Facility: <br />U 8C. Alternate Facility: <br />U 8D. Alternate Facility: <br />dcycle, Inc. <br />Martcycle. Inc. <br />Siaricycle. Inc. <br />4135 W. SvvittAw <br />90 N. Foxboro Drive <br />13651 Shabn Dove <br />,.t 17 <br />North Seat Latae, UT 84064 <br />Hollister, CA 95023 <br />(866)7M7422 <br />(86b)783-7422 <br />TS/OST223A-Et48,}A <br />38 <br />MOST 83 <br />MAY 16 M 7 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have <br />received the at by-e,joiggfed wastes in accordance with the requirement outlined in that authorization <br />Printfrype Name <br />Signature <br />Date <br />Transferredcontainers, <br />cult to ' <br />ORIGINAL <br />Cu <br />