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MEDICAL WASTE TRACKING FORM NUMBER <br />+®r Sj e�°N���1e` CA OFT RGEN�jY CONTACT: CHEMTREC 1-800-4241 STANDARD MANIFEST 001.10.06•STD <br />PmtoclingPeopfe.ecduJng6l.k' <br />Rote " 3'` `�' CUSTOMER NO. 21132 MDFROOJJIV' <br />on T.It ID <br />1. Generator's Name, Address and Telephone Number <br />ATT[: <br />GILL MEDICAL CEETNATM <br />STOc11=1 �IrAO�952b4T 6117 <br />451-9031 <br />8/15/2027 <br />6111852-001 <br />CUSTOMER NtIMaER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE <br />2C. NO. OF <br />2D, VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., <br />TBQS — 40 Gal Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n o s., <br />_ if Gat WON kato) <br />6.2, PGII <br />Cu Ft. <br />® <br />UU232P9G1 ;Regulated Medical Waste, n o s , <br />Y Cu Ft. <br />4 <br />UN3291 Regulated Medical Waste, n o.s., <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />io — a C etno a l Tub(4.14CUET) <br />6.2, PGII <br />Cu Ft <br />tZ <br />Or <br />UN3291 Regulated Medical Waste, n.o s., <br />TdEC3— (Bio) PW43— (Path) CW43— (Chemo) Gal Tub (S • 7CUFT) <br />6G1' <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />M — Biosystems Cardboard Box (4.2 cu ft) <br />6.2, PG If <br />" — <br />Cu Ft <br />11143291, Regulated Medical Waste, n.o.s., <br />6.2, PGI) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />TOTALS ® <br />twator's Certification: °t hereby declare that the contents of this consignment are fully a2...,aca <br />des 21 above by the shipping name, and are classified, packaged, marked and fab Iand <br />Cu Ft. <br />proper <br />star In ai es�pools In�proppeerrccondition <br />�transport according tt(q applicable international and atregulations'/(".Prl <br />ljfor <br />6 <br />Dae ` /J / <br />ad7TypAd Dame e� Si <br />4.11RPORT F iATlwaler xnC. This is a Thr-1WShipment <br />y r <br />4135 W. Swift Ave Hauler Permit Numbers: <br />a <br />Eresna,CA 93722 <br />U) <br />TRANSPO �ER 11=1C : Receipt of medical waste as des abed a ove <br />j <br />} <br />Printttype Name ! ,`_`� Signatur <br />Dale <br />5. INTERMEDIAT ANDLER 2 / TRANSPORTER -2 ODRESS- <br />Phone #: <br />N <br />� <br />Applicable Permit Numbers' <br />ar� <br />o <br />oH <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />0 <br />Applicable Permit Numbers: <br />N a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Q�x <br />�- <br />PrinMpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Facility. <br />❑ SD. Alternate Facility: <br />6A. Deal ted Facility: 8B. Alternate Facility: 8C. Alternate <br />teripycld hmaOATIZ Sterlaycle, Inc. Stericycle, Inc. <br />4135 W. SWlit Ave So N. Foxboro Drive 1551 Shelton Drive <br />if <br />Fresno,CA 9372 North Salt Lake, LST W54 Hollister, CA 95023 <br />066M,741% 417 1;866)783-7422 (86}x)783-7422 <br />UJI <br />S/02 3A -448 -JA -36 TSIOST 83 <br />W <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 />t - <br />received the above indreateol wastes in accordance with the requfrement outlined in that authorization. <br />Printlrype Name MR <br />Date <br />eu III fill <br />Cp <br />on T.It ID <br />