|
a T MEDICAL WASTE TRACKING FORM NUMBER
<br />®90ASE® Stertcycle° OF EMERGENCY CONTACT: CHEMTREC 1-800-424- 00 STANDARD MANIFEST 001 -10.06 -STD
<br />° Pletedlnphople.KetlutinpQbk: Route #: 123 -- 16 CUSTOMER NO, 21132 MI)FROORM
<br />1. Gt3nerator'e Name, Address and Telephone Number
<br />ATTN: jf Ij ij
<br />GILL MEDICAL CENTER -
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031 8/8/2017
<br />CUSTOMEnNumorh 6111852-001 GENERATOR'sRrzGisTRAn0N#
<br />2A. DESCRIPTION OF WASTE 2B• CONTAINERTYPE
<br />UN3291 Regulated Medical Waste, n.D.s., TBO5 — 40 Gal Tub (Bio) (5, 3 cu 'ft)
<br />6.2,1368
<br />UN3291 Regulated Medical Waste, n.o.s., TB49 — 37 Gal 'tub (Bio) (4.9 cu ft)
<br />6.2, PGIJ
<br />X UN3291I Regulated Medical Waste, n.o s, 614 44 Gal Tub (Bio) (5.9 Cu ft)
<br />C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />Cu Ft
<br />®
<br />6.2, RGI
<br />Cu Ft
<br />Q
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />T1321— (BT(?) TL315— (Path) /TY.15— (Chemo) 20 coal Tub (2.7CUFT)
<br />6.2, PC It
<br />Cu Ft
<br />W
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />WB31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal. Tub (4.14CUFT)
<br />ZZ
<br />6.2, PO [I
<br />Cu Ft.
<br />�e
<br />8 UN3291Regulated Regulated Medical Waste, n.o.s.,
<br />WB63— (Bio) /LIW43— (Path) /CW43— (Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft.
<br />62, PPoll Regulated Medical Waste, n.o.s.,
<br />KRB _ Biosystems Cardboard Box (4.2 cu Et)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />6.2, PGII
<br />Cu FT
<br />UN3291Regulated Medical Waste, n.o.s.,
<br />PGII
<br />6.2,
<br />Cu Ft
<br />3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®TALEtOo t Cu Ft.
<br />ds above by the proper shipping name, and are classified, packaged, marked and labelled/ d d
<br />In at spects In prop" edition for transport accor g to applicable International and nate I ov r ntal regulate s
<br />Prin dtlyped Name Signature
<br />Lu
<br />4.TRAN 0 E 1 ADDRESS: ne( 66) 83-7422
<br />Stericycle, Inc. This as a T Lough shipment
<br />a
<br />4135 W. Swift Ave A i1, a Permit Numbers:
<br />Hauler Reg# 3404
<br />a.
<br />Frenno,CA 93722
<br />a. ¢
<br />TRANSPORTTIFiCA : Receipt of medical waste as descreb ova
<br />W
<br />Print/Type Name Signature Dale
<br />5. INTERMEDIATE DLE 2 /TRANSPORTER 2 ADDRESS: Phone lf:
<br />N
<br />Applicable Permit Numbers:
<br />ama
<br />Ca
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVrype Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS- Phone it -
<br />Applicable Permit Numbers:
<br />N d a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicai waste as described above.
<br />2Vl
<br />Q� —
<br />PrinVlype Name _ Signature Date
<br />7. DISCREPANCY INDICATION
<br />}
<br />Designated Facility:
<br />80. Alternate Facility:
<br />❑ 8C Alternate Facility:
<br />❑ BD. Alternate Faculty:
<br />t
<br />cycle, inc.
<br />Stedaycle, Inc.
<br />Stericycle, Inc.
<br />U415
<br />SM AVO
<br />90 N. F4Xbor* DMV*
<br />1651 Shelton DriveFresno,CA
<br />if
<br />gZI722
<br />North Safi Lake, UT 841284
<br />Hollister, CA 95023
<br />�& t�r{NE aRit2
<br />SA644 X36
<br />i2 II
<br />C
<br />TS/OST 834'2
<br />,��t3 U IR11 I
<br />TREATI!~ CLI [certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined In that authorization.
<br />Print/T'yps Name <'Y Sicinature
<br />TTarisferred cantallilers, Cut 11! to
<br />� I
<br />Q
<br />OMGINA1_
<br />
|