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MEDICAL WASTE TRACKING FORM NUMBER <br />®`' E RFCY COM <br />STANDARD MANIFEST 001-10.06-STDO®®O StericClsa 4 Nt�rROQ <br />JAVY <br />pi.wd"hople.R.a.IneRIA. CUSTOMER NO. 21132 <br />see:aeeaecseaeau 6:6!#tBa�t{rlGtny ut tt itu <br />ORIGINAL <br />t. Generator's Name, Address and Telephone Number <br />ATT LS 1 it it 11 <br />it11 tt i1 11 11 11 11 <br />GILL MICAL CEMERR <br />1617 N C'ALIFORRIA ST <br />STOCKTon, CA 96204- 611.7 <br />(209) 451-9031 6/13/2017 <br />� <br />CUSTOMER NUMBER GENERATOws REGISTRATION ff <br />2A. DESCRIPTION OFWA$TE <br />2B. CONTAMERTYPE <br />20. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., <br />TROS — ESQ +Sat Tuft fl i o) (5.3 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />— o Cu t <br />6.2, PGII <br />Cu Ft. <br />X <br />UN3291-, Regulated Medical Wast% n.o.s., <br />u o - Cu <br />® <br />6.2, PGII <br />Cu Ft. <br />4 <br />UN3291 Regulated Medical Waste, n.o.s., <br />at1x)iTY±5-(Chrjuv)2(j 031 y <br />6.2. PGII <br />Cu Ft. <br />to <br />UN3291, Regulated Medical Waste, mos, <br />_ a Pati 6W. — (Chen*) 1 Gal Tub(4.14C <br />T) <br />6.2. PGII <br />Cu FL <br />iZ <br />�e <br />UN3291 Regulated Medical Waste,n.o.s„ <br />Gat Tub(5-7C[IFT)6.2. <br />PGli <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o,s„ <br />KF3 — Biosystems Cardboard Box (4.9 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, MOS., <br />6.2, PGII <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accura ly TOTALS ® t <br />Cu Ft <br />des above by the proper shipping name, and are classified, packaged, marked and labelled lacard d, and <br />n all pacts in proper ondition for transport according to appliiccabbblle' international and na nal0oover mental r ulatio ." <br />{ <br />V 1Prin `Z <br />f dlryped Nam O �'" ""' Sig arf tore mate <br />4. IRAN DATER i ADi f �.iG'�(I1113, Itl . ® This 2hrrlugh Skt3.pment Phone #. d <br />Lu <br />4135 TO. Swift: Ave Applicable Permit Numbers <br />Rrrg# 3404 <br />oFuesttt},CA <br />93722.?3atxlt�c <br />N <br />a a <br />TRANSPORTEP-CERTIFICATlQ#Wq Qpceipt of medical waste as descnb <br />Print/Type Name Signature Date <br />5. INTERMEDIATE DLER 2 TRANSPORTER 2 ADDRESS: Phone # <br />0: 12 <br />Applicable Permit Numbers. <br />g <br />0 <br />C)Ujo <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recaipt of medical waste as described above. <br />PrInVlMpe Name Signature Date <br />aApplicable <br />6. INTERMEDIATE HANDLM 3 /TRANSPORTER 3 ADDRESS: Phone # <br />0 <br />Permit Numbers: <br />N <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />fE <br />PrInMpe Name Signature Date <br />T. DISCREPANCY INDICATION <br />A. Dosignated Facility: BB. ARernate Facility: 8C. Alternate Facility: 8D.Altemato Facility: <br />ricycta, inc. Stericyde. Inc. St,3rlWale, Inc. <br />I �5 W,� . 90 N. Faboro DrNe 1551 Shefton Drt" <br />rS�oW�IRi►� <br />Y5FtX0� North Stilt Late, LIT 84054 Hollister, CA 95023 <br />(B66)7M742e2 <br />(KS)783-7122 (8156)793-7422 <br />LU <br />4 <br />aRr448,14.3E Ta,}}OET £3 <br />1UN <br />TREATMENTLOW��•certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />I— <br />received the above incircated wastes in accordance with the requirement outlined in that authorization. <br />FrinMpe Name Signature Date <br />see:aeeaecseaeau 6:6!#tBa�t{rlGtny ut tt itu <br />ORIGINAL <br />