|
T MEDICAL WASTE TRACKING FORM NUMBER
<br />• ® "
<br />0®O S'�Qj"(cyCiQ• CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-4240 STANDARD MANIFEST 001.10.06 -STD
<br />®® Pm1"11.gP6.Pl4.Red091nRRlck: Route 9: 123 — 20 CUSTOMER NO. 21132 M FR0C1. FjG
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />A` N -. ,1111111111111111111111111111111111111111111111111
<br />GILT, MEDICAL CE19'I'EFt
<br />1617 'N CALIFORNIA ST
<br />STCCMN, CA 95204- 6117
<br />(204) 451-9031 7/18/2017
<br />CUSTOMER NUMBER 61-11852-001 GENERATOR's REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, .o s.,
<br />n
<br />THOS _ 40 Gal Tub (gig,) �)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291Regulated Medical Waste, n.o,s.,
<br />6.2, PGII
<br />TB49 - :37 Gal Tuts (Rio) (4, 9 ecu ft)
<br />Cu Ft.
<br />it
<br />UN3291, Regulated Medical Waste, n.o s,
<br />q 44 Gal Tub (Biro) (3.9 ecu ft)
<br />®
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291Regulated Medical Waste, n,o s.,
<br />TB21— (BIO) /TP-tS— (Pet21)TY1S— (Cheno) 20 Gal Tub (2.7C1IFT)
<br />cc
<br />6.2, PGII
<br />Cu Ft.
<br />UI
<br />UN3291, Regulated Medical Waste, n.o.s ,
<br />Wg31- ( i3f o) /WP31- (Path) /WC31- (Chemo) 31 'Gal Tub ( 4.14=
<br />)
<br />Z
<br />62, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI!
<br />WB43- (Hio) /Pw43- (Path) /CW43- (Chemin) Gal Tub (S.7CEIPT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />PGII
<br />IULB — Biosystems Cardboard Box (4.2 cu ft)6.2,
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste,
<br />6.2, PGII
<br />Cu Ft,
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TA[.S �' s Cu Ft.
<br />hipping name, and are classified, packaged, marked and labelle ..,and
<br />described above by tjer
<br />are spscts Indition for transp t according to applicable International and nat al ve ntal requlaUone
<br />�~
<br />Prin d(Typed Signature Date
<br />PORTER 1 ADDRESS: Phone M. (81- 83-7422
<br />st:f:,�,ri6cie, Inc. ® This Is a Through Bhlpment Applicable Permit Numbers-
<br />I-
<br />a
<br />43-x5 1p. Swim Ave
<br />Hauler Fteg 3A150
<br />O
<br />Ft+?�no,CA 93722
<br />a Q
<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as descnb ab a P
<br />F-
<br />��
<br />PtinMpe Name Signature Date
<br />5. INTERMEDIA AN LER /TRANSPORTER 2 ADDRESS: Phone #.
<br />cc
<br />Applicable Permit Numbers.
<br />Ono
<br />N
<br />INTERMEDIA ANDLER /TRANSPORT R CERTIFICATION eceipto medical waste a s nbed above.
<br />—
<br />PrInMpe Nae 7 Signature Rate
<br />m
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />accApplicable
<br />a
<br />Permit Numbers.
<br />0* cl
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />z�s
<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />J�r8A. Designated Facility: 0 86. Altemate Facility: D 8c. Attemate Facility. r] 8D.Altemate Facility:
<br />s
<br />cycle, Inc. Stericycle, Inc. Sterlcycle, Inc.
<br />4136 W. SWittAya 90 N. Foxboro Drive 1551 Shelt3an ©rive
<br />u
<br />Fresno.CA 93722 NofthSalt Lake, UT !34054 HoUlsbar. CA 9023
<br />1—
<br />(866)783-7422 (M)783-742" (SM)783-7422
<br />t.0
<br />V�0-? Oil 3A- $ Ar38 TSMT83
<br />t--
<br />uU :s
<br />TREA ��1f[[ N IF, Cjji��jj11: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />h
<br />receiv it'tt above I dated wastes in accordance with the requirement qutllned In that authorization.
<br />PrintrrypeNel�i dtlr. � Signature Date
<br />Transfirred canto hers, CU ft to
<br />ra
<br />ORIGINAL
<br />
|