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<br />QASE OF EMERGENCY CONTACT: CHEMTREC 1-800424-9
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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 />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />GILT. 14EDIM CLiITER
<br />161.7 'N CALIFORT41A ST
<br />STOCKTON, CA 95204- 111
<br />CUSTOMEn NUMBER ,� _ GENERAToms REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />23. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6.2, PGiI
<br />TBOS - .41) ►Tal Tub (13i of (5.2 cu ft-)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.os„
<br />6.2, PGII
<br />7849- 37 tial Tub (r�i or (4, 9 CU ft)
<br />Cu Ft.
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<br />G 2, PGII Regulated Medical Waste, n.o.s.,
<br />,14 _ 4,4 Gal Tim ��� �Fy # � � y �u i t�
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />t1-#sral,riP35- #Path} / 1`XJ 5- #t:h>=sBtr} r(I Gal Tttl (2-7CFJFT)
<br />6.2, PGII
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<br />UN329t Regulated Medical Waste, n,e s,
<br />6.2, PGI
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<br />UNS291 Regulated Medicai Waste, n os.,
<br />6.2,PGII
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<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n o.s.,
<br />6.2, PGIi
<br />Kph, - Bioffyst-m- t Cardboard Box (q-2 ctx '�'tl
<br />Cu Ft.
<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 />6.2, PGII
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<br />3. Generator's Ceirttficsition: "I hereby declare that the contents of this consignment are fully and ace tely ®TALS r"'
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<br />dose d bove by the proper shipping name, and are classified, packaged, marked and labelled/pl r , and
<br />n a re pacts in proper condition for transport accordingtoapplicable international and natt go me9
<br />I.tSign—,Datl
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<br />yped Name to
<br />PORTER 1 ADQRESS: ;^--�Phone
<br />:StP_L'iG f`1r_ IItiC. L.d This -is a Through/Shipment
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<br />Applicable Permit Numbers:
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<br />41.35 W. Swift Ave
<br />Hauler Reg# 3400
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<br />r,vema,cA, 93722
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<br />TRANSPORTEtj,L:FRTIFECATI ecelpt of medical waste as descri d abo
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<br />PrinV type Name Signature
<br />Date _ I
<br />5. INTERMEDIATE HA DLER 2/TRANSPORTER 2 ADDRESS:
<br />Phone 4
<br />SApplicable
<br />Permit Numbers:
<br />ouilloll
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUTypo Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone N:
<br />aApplicable
<br />Permit Numbers.
<br />0
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />a�=
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<br />Print/Type Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
<br />y
<br />11-
<br />OA.Deal na acillty: D aB. Altemate Facility: ®eC. Aitemate Facility:
<br />®3D. Alternate Facigty.
<br />Sterlcycle, inc. Sterlcycler Inc. Stericycle. Inc.
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<br />TREATMENT FACI ITY: I ce}tify that I have been authorized by the applicable state agency to accept untreated
<br />medical wastes and that i have
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<br />received the, krri`d1& e'I:,40astes in accordance with the requirement outlined in that authorization.
<br />Printrlype Name S nature
<br />Date
<br />�1
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<br />ORIGINAL
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