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<br />• Ndullne People Aedudng Risk'
<br />CASE OF EMERGENCY CONTACT: CHEMTREC 1.800 -424-
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<br />CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001-10.06•STD
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<br />1. Generator's Name, Address and Telephone Number
<br />i I
<br />GILT, WDICAL (7SINTER
<br />1617 Ti CALIFORNIA ST
<br />S�-N, CA 95204- 61.17
<br />.,
<br />CUSTOMER NUMBER , GENERATOn's REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAtNERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medicai Waste, n.o.s.,
<br />6.2, PGII
<br />CONTAINERS
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<br />UN3291, Regulated Medical Waste, n o s.,
<br />6.2, PGII
<br />TB49 — 37 Gal flub Bile 4.9 cu f
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<br />CC
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />9
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<br />6,2, PGII
<br />TB14 — 44 0Ml Tub Bio 5.9 eu tt
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<br />CC
<br />S,N23291 PGI� Regulated Medical Waste, n.o,s.,
<br />TS21— (SSQ) /TP1S— (Path)/TYIS— (Chem*) 20 Gal Tub (2.7iCUPT
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGtl
<br />wn3i— Sia tdg31— Pati:)ltim32— :Chema 3
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<br />UN3291 Regulated Medical Waste, n o.s.,
<br />6.2, PGII
<br />WBA_ (Ri_fCbx-mo;1 8a3 xub0_7cuFTx
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<br />UN3291 Regulated Medical Waste, n o,s.,
<br />6.2, PGII
<br />_fix
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<br />UN3291, Regulated Medical Waste, n o s.,
<br />6.2, PGiI
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />62, PGI
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<br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately TOTALS ®
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />tt(according to applicable Internationaland national governmental regulations"
<br />are in all respects in proper conditi n for transport
<br />fSPrinted/TypedName ` l (Af `l/w�
<br />—Data
<br />° ° `' Signature
<br />4. TRANSPORTER i ADDRESS:
<br />Phone #: tt u�t
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<br />atericyCle, Inc. Ttas isaTttougP=
<br />e :742
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<br />4135 V. Swift Ave
<br />Hauler Reg-* 3400
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<br />I's"eana,CA 93722
<br />TRANSPORTEA CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVlype Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />oho
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrfnUTMpe Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS-
<br />Phone #.
<br />°; g
<br />Applicable Permit Numbers:
<br />d a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />�P-1x
<br />—
<br />Prinnpe Name — Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Altemate Facility:
<br />Doslgnated Facility: 8B. Altemete Facility: 80. ABemate Facility.
<br />8D.
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<br />Stericycle, inc. Swtyde. inc. Stericycle, Inc.
<br />41136K
<br />va 90 N, Grua Drive 1661 Shelton Dive
<br />13 2 North Salt Lake, UT $4054 Hollister, CA 96023
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<br />9ii } 8 7
<br />(888)783-7422aTS/
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<br />TS/OST 83
<br />017
<br />TREATMENT FACILITY: I certify that i have been authorized by the applicable state agency to accept untreated medical wastes and that i have
<br />I--
<br />received t ,&Vov 1ihdicated wastes in accordance with the requirement outlined In that authorization.
<br />Print/Type Name Signature
<br />Date
<br />::Transferred _ cotttalners, cu tt to
<br />C+7TC�TFi`Ti>t
<br />
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