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<br />MEDICAL WASTE, TRACKING FORM NUMBER
<br />Dj&W4F0EIjyjCY1COjWCT: CHEMTREC 1-800.424-9 0 STANDARD MANIFEST 001-10.06•STD
<br />CUSTOMER NO. 21132 MOFROLlclr83W
<br />It ORIGINAL
<br />12
<br />1. Generator's Name Address and Telephone Number
<br />AWN
<br />111111111111111
<br />GILL MEDICAL
<br />1.61.7 iR CALIFOR1111A ST
<br />STPD, CA 952174— 61.1.7
<br />(209) 451-5031 5/23/2017
<br />6111852-001 GENERATOR'S REGiSTRATfON #
<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OFWASTE
<br />2f3. CONTAINER TYPE
<br />2C. NO. OF 2D. VOLUME
<br />UN3291', Regulated Medical Waste, it o.s.,
<br />TBO5 — 40 Gal Tub (13io) (5.3 cu ft)
<br />CONTAINERS
<br />6.2, PGiI
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<br />UN3291, Regulated Medical Waste, n o.s.,
<br />cu
<br />6,2, PGII—
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<br />UN3291, Regulated Medicai Waste, n,o s.,I&AI
<br />CU
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<br />6,2, PGII
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<br />UN32911 Regulated Medical Waste, n,o,s„
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<br />6,2, PGil
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<br />UN3291, Regulated Medical Waste, n,o.s.,
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<br />Z
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.—%S.,'o
<br />— d — C ° 6a T C -UFT
<br />6.2, PGII
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n o s.,
<br />.._ osy dard Bax cu ft
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGiI
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />6.2, PGiI
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />jl
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<br />bove he hipping name, and are classified, packaged, marked and labelledlplacarded, and
<br />d"Inall
<br />Bite!s s roper con itlon for transport according to applicable International and national governmental regulations.'
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<br />3�
<br />Signature Date
<br />4.T SPO TER 1At iiZS@ C IF", xt1G� ® This 3s Through tsi>t3pr�etst Phone #. —
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<br />4135 p. Swift Ave- Appli ble Permft Numbe
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<br />1 3400
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<br />'E'irenno,CA 93722
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<br />TRANSPORTS R FICATION: Receipt of medical waste as dkebove.
<br />j
<br />Print/lype Name Signa ur Dat
<br />6. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS, Phone #
<br />Isss�iccc
<br />Applicable Permit Numbers;
<br />�
<br />N�
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />j
<br />Pr!nVrype Name Signature Date
<br />6, INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone #
<br />g
<br />Applicable Permit Numbers,
<br />0
<br />04.0
<br />s
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />x
<br />PriniR•ypo Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />y
<br />. D gn ted act ity. ❑ 8e. Alternate Faculty- eC Alternate Facility: ❑ 8D Alternate Facility:
<br />41St 9Q FM&M matt
<br />—t
<br />N UriA 1551 drive
<br />a
<br />F With a'alttalm LIT 840S4 Hollister., CA SSW
<br />(8783-7422 (8GG)783-7422 (8783-7422
<br />�
<br />3 2017 �1' 83
<br />lu I, TREATMENT F`�Ct i 11 -�f certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />N
<br />received the above fndtcate(i wastes In accordance with the requirement outlined in that authorization.
<br />PrinMpe Name S11ro Date
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<br />It ORIGINAL
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