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<br />OCASE OF EMERGENCY CONTACT: CHEMTREC 1-800-42*0
<br />Katie 0: 123 _ 21 CUSTOMER NO. 21132
<br />MEDICAL WASTETRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10.06 -STD
<br />MDFROOMF
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />GILL 14EDICAIL CENTER
<br />1617 N CALIEAR14IA ST
<br />STOCXTOId, CA 95204— 6117
<br />f2t�9� 951--51131
<br />l:",/6J'2ti3.7
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />CONTAINERS
<br />6.2, PGI!
<br />TBE -5 - 40 Gal Tub (Bio) (5.3 cu tt)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, P811
<br />T1349 - 37 Gal Tub (Biu) (4.9 cu ft)
<br />Cu Ft.
<br />®
<br />823AGI� Regulated Medical Waste, n.o.s.,
<br />B14 - 1 Gal Tuft (Hitt) 0.9 Cu 116;Cu
<br />Ft
<br />6 23291 PGI(Regulatad Medical Waste, n.o.s.,
<br />TR2y_ (Raga) /TPI5- (Path) /TY15- (chemo) 2u Gal Tub (2.7C
<br />T)
<br />Cu Ft
<br />W
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2,PGiI
<br />t�831-{$fad/ut�31-(Pati')/ittt~3J-(Chemo)31 Gal Tttb(4..t4fi
<br />FT)
<br />Cu Ft
<br />u
<br />Regulated Medical Waste, n.o.s.,
<br />6.2 1 PGI
<br />WB42 - (Rio) /PW43— ( Path) /CW43— (Chemo) Gal TEtb (5.7CUFfi)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o s.,
<br />6.2, PGiI
<br />KRB - Biro steins Cardboard Box (4-2 cu ft)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6 2, PGI1
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, rias.,
<br />6.2, PGII
<br />Cu Ft
<br />dorator's Certification: 11 hereby declare that the contents of this consignment are fully and acc tely TOTALS ►
<br />Cu Ft.
<br />desc ed above by the proper shipping name, and are classified, packaged, marked and label d/place ed,
<br />are In 11 respects In proper co clition foi� pori apco g t �applicab a ntarnational and n I net ve n ent u ns,"
<br />\V1
<br />}J
<br />rintedriyped Nama _,11 Sign ur
<br />Date
<br />CC
<br />4. ANSPORTER 1 ADDRESS:
<br />Phone sh
<br />7$3-7422
<br />Stericycle, Inc. Vii s z a Through Stxi utenc
<br />Applicable Perm !Numbers
<br />oc a o
<br />4136 W. Swift Ave
<br />Hauler Reg# 3400
<br />E EL
<br />Fresno, CA 9:3722
<br />a a
<br />TRANSPOR RTIFI N: Rec t of medical waste as closer
<br />ice—
<br />PrinVrypo Nam Signature
<br />bate
<br />S. INTERMEDIATE HAN L R 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />aAppiicable
<br />Permit Numbers,
<br />9L
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUrype Name Signature
<br />Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone #:
<br />ain
<br />Applicable Permit Numbers
<br />0
<br />a
<br />'INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />fE
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: [] 85, Alternate Facility: 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />—'
<br />Stericycle, Inc. Stericycle, Inc. Stericycle, Inc.
<br />w
<br />4196 $v Ttz 80 N, Ftl tro DM 1651 Shelton Drive
<br />Fresno,CA 93722 North Salt Lake. UT 84054 HoWster, CA 8$1323
<br />(86'=)713 7422 (886)783-7422 (866)783-7422
<br />T13J 0 6 2017 8 -JA, -29 IWOST 83
<br />d
<br />.
<br />Lu
<br />TREATMENT FAQ ,,,,ttify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F-
<br />received the above indica# wastes in accordance with the requirement outlined in that authorization
<br />PrinVType Name Signature
<br />Date
<br />Transferred cantafnersa ou 11 to
<br />ORIGINAL
<br />
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