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0 , Stericycle* <br />• Weding Peopre.Aeduding RIA: <br />40CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.42401 <br />Route #4 123 — 8 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -10.06 -STD <br />1115 ..#T I x r it <br />ORIGINAL f' >y <br />1. Generator's Name, Address and Telephone Number <br />i <br />GILL Nll;'f)ICAL am'L'>$R <br />1617 N GALIPO NTA ST <br />STOCKTON, CA 35204- 6117 <br />203 451-9031 � <br />CUSTOMER NUMBER 61U852-001 GENERATOR'S REGISTRATION If <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />llN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />6.2, PGII <br />TROS — 40 Gal Tub (Rio) (5,3 au ft) <br />Cu Ft. <br />UN3291Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TBk9 " 37 Gal Tub (Hio) (4.9 Cu ft) <br />Cu Ft. <br />O <br />6N3291, Regulated Medical Waste, n.o.s., <br />ax4 44 Gal Tub (Dio) (5.9 eau 10 <br />Cu Ft. <br />aUN32911 <br />Regulated Medical Waste, n.o.s., <br />'01- (BXO)/TP15-(Fath)j?yt5-jChemo)20 tial Tub(2.7CEIFT) <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGIi <br />V031- Wio) /WP31- (Path) /WIC31- (Chemo) 31 Gal Tub t 4.14CiF) <br />Cu Ft <br />IZ <br />O <br />Regulated Medical Waste, <br />6.23PGlI <br />WBt3— (Bio).tPK43— (Path) /CWs13— (Chinn) Gal Tub 5.7CUFT <br />Cu Ft <br />UN3291 Regulated Medlcal Waste, n.a.s., <br />6.2, PGII <br />KPJ3 — Sioqystms Cardboard Bax 4.2 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated M`edlcal Waste, n.o.s., <br />I <br />6.2, P61I <br />Cu Ft <br />3. Generator's Certification: •i hereby declare that the contents of this consignment are fully and accurately TOTALS ► Cu Ft. <br />de be above by the prayer shipping name, and are classified, packaged, marked and labelled/pl arded, and <br />tt r In it r spects In proper condition for transp rt acc rdmg to applicable ]ntemationai and natio v rn nt regulations:' <br />! <br />1 <br />I P tednyped Name;r�u(1~' Si ol <br />U.1 <br />SPQRTER i ADORES$: ;; Phone #: {,} #� <br />stericycle, Inc. This -is a Through Slv.placmt AAPScable SmiTiVu�m'bers•�� 2 <br />1.! <br />a <br />4135 W. Swift: Ave <br />a O <br />na. <br />Hauler Regi 3400 <br />Ftasno,CA 33722 <br />E <br />Z <br />TRANSPORT ERTIF ON: Recelpt of medical waste as describe bov r"') j ( J J1 »� <br />Prinmpe Name Signature Date C! If /J <br />6. INTERMEDIATE ANDLER 2/TRANSPORTER 2 ADDRESS. Phone #. <br />110§ <br />Applicable Permit Numbers <br />HO <br />to <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrintMpe Name Signature Date <br />m <br />are <br /># <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phonerc <br />0 <br />Applicable Permit Numbers <br />N d <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />x <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />>» <br />eA Dosignated Facility; ® Be. Alternate Facility: ❑ SC. Alternate Facility: [i 8D. Alternate Facility: <br />-'a. <br />Inc. Swdgtote, Ina. Shnicide. Inc. <br />3-5-W. <br /><41 <br />SWR Avo 90 N. Foxbom DrMitt 1561 SMbn Orl a <br />u <br />F'reano,CA 93722 North Salt Faire, LIT 84M HoWsf ar. CA 951323 <br />df }71 d1�21z {t is3-7a22 (866)783-7422 <br />Tfi��ft3slf7q" 2 3AA 8 -JA -36 xt'�I' <br />p 83 <br />x pin <br />77 <br />TREA�tMEN� FA3�qqITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />I-- <br />11 <br />received the above indicated wastes In accordance with the requirement outlined to that authorization. <br />PrinUlype Name Signature Date <br />ORIGINAL f' >y <br />