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MEDICAL WASTE TRACKING FORM NUMBER
<br />O® ®O Stericycle° OCASE OF EMERGENCY CONTACT: CHEMTREC 1-800.42 - 0 STANDARD MANIFEST001-10.06-STD
<br />• rrouciln9reapla itedudny Risk.* RA-11te, �.; 123 - 15 CUSTOMER NO. 21132 14DFROOJCCI
<br />ap r r,ef,r 1--11 rlm i- l,T: i certity that r nave Deen autnonzea by the applicable state agency to accept untreated medical wastes and that I have
<br />t- received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Typo Name
<br />Signature
<br />Tranderred corttafnera, cu ft ter
<br />Date
<br />1. Generator's Name, Address and Telephone Number
<br />AW14: 111111111111111111111111111111111111111111111111111
<br />GILL MEDICAL C_'TtaIrM
<br />1617 19 CALIFORtITIA ST
<br />STD(. ,7011, CA 95204- 6117
<br />(209) 451-9031 6/27/2017
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTP-
<br />28. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />6.2, PG Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TOYS - 40 Gal '.Gula (tii.ra} (5.3 cax -Et}
<br />CONTAINERS
<br />Cu Ft
<br />UN36.21 PGII 91Regulated Medical Waste, n.a,s.,
<br />T849 - 31 G;si Tub Misr} (4.9 cu tt)
<br />IL Cu Ft.
<br />X
<br />0
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />��� _ `�uh� i#Ira}� Ou ttj
<br />Cu Ft.
<br />2329 i Regulated Medical Waste, n.o.s.,
<br />T821� t>3x� /TP1S- �Patl�} /Ty15- qc�� aa} 2> t Gal Tub 42.7i u
<br />)
<br />6
<br />Cu Ft.
<br />U1
<br />UN3291 Regulated Medical Waste, n.c.s„
<br />6.2,PGII
<br />(231- (Eio )/PJP31--SFat]y)/tttt..31-(t''l)ejnkv)31 Gal Tub(4.14C'Ef
<br />T)
<br />Cu Ft
<br />tZ
<br />6.23291 PGiIRogulatedMedicalWaste,n,o.s„
<br />�¢ -4 �} � �3-t ,�r��)/��tct63 {E;i2e3ao) real Tub(S.70UPT)
<br />Cu A.
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />KRB - Bi ozyst ems Cardboard Box (4.2 e;;u it)
<br />Cu FL
<br />UN3291
<br />aced Medical Waste n.o.s.,
<br />6.2. P 1
<br />Cu Ft.
<br />UN3 91 Rcg aced Medical Waste, n.o.s.,
<br />6.2 PGII
<br />Cu Ft
<br />Gene tor's Certification: "I hereby declare that the Contents of this consignment are fully and accurately TOTALS ` e Cu Ft.
<br />describ d above by the'pr6per shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are In it respects in props{ c ndition for transport actor ing to applicable International and national governmental regulations:'
<br />M t`
<br />i 1 �$
<br />Printed/typed Name \� Date( "�
<br />w
<br />_—Signature
<br />ANSPORTER 1 ADDRESS: Phone #: (066) 783-7422
<br />3tr:t_•:Ulyt:1e, int_. Ttds is a TUrough Stdpm.etrt
<br />Applicable Permit Numbers:
<br />�i rc
<br />41:35 v. swift: Ave
<br />-
<br />< 4
<br />Mw
<br />Hauler Fteg# :3400
<br />FCa3vttr-„rA 9;3722
<br />poli 4
<br />0�'
<br />TRANSPORTER C RTIFICATION: Receipt of medical waste asdescr hove.
<br />PrinUiype NameAw�Signat Date Z�
<br />.�
<br />S. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone #:
<br />N
<br />4
<br />Applicable Permit Numbers:
<br />a �
<br />U =
<br />H
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />-
<br />PrinViype Name Signature Date
<br />cc
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />J
<br />N a
<br />INTERMEDIATE: HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />a�x
<br />�-
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />"r
<br />8A. Doslgnatod Facility:
<br />'a`terlG}}�C--IB
<br />68. Alternate Facility:
<br />8C. Alternate Facility:
<br />E] BD. ARarnate Facility:
<br />-=
<br />IriC.
<br />41�.�!�d�'�
<br />Stericycle, Inc.
<br />Sler{C de, Inc.
<br />20 N. Foxb%W Drf”
<br />1651 shre tion I]rly"3
<br />a-
<br />Fresno,CA 93722
<br />Alorth Salt take, Ur 840%
<br />Holllsbar, CA 95023
<br />[fill
<br />=V1617j8t">?�783-?gl4'r
<br />1'8tity' �}283-7�t22
<br />SPA4844-36
<br />TIJI- OST 23
<br />M=
<br />ap r r,ef,r 1--11 rlm i- l,T: i certity that r nave Deen autnonzea by the applicable state agency to accept untreated medical wastes and that I have
<br />t- received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Typo Name
<br />Signature
<br />Tranderred corttafnera, cu ft ter
<br />Date
<br />
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