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<br />CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424 0
<br />Route #: 123 — 16 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10.06 -STD
<br />Transferred c:ontalners, ou ft to
<br />7. Generator's Name, Address and Telephone Number
<br />AT`i'N 11111111111111111111111111111111111111111111111111111
<br />GILL MEDICAL CE14TER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 61:17
<br />(299) 451-9831 8%22/.2917
<br />CUSTOMER NUMBER 6111852-001 GENERATORS REatSTRAVON #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Rogulatod Medical Waste, n.o.s„
<br />fi,2, PGI)
<br />TB05 — 40 Gal Tub (Bio) (5.3 Cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />UN32911 Regulated Medical Waste, n.o,s.,
<br />6.2, PGIi
<br />TB49 — 37 Gal Tub (Rio) (4.9 Cu it)
<br />Cu Ft.
<br />pC
<br />UN329i, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TBI _ 44 Gal Tub(Bio) (51 9 ru f b'
<br />O4
<br />O4cc
<br />Cu Ft
<br />6 2320 j Regulated Medical Waste, n.o.s.,
<br />'xBa1- (HXQ) /TV15- (Pat:h) /TY15- (Ghana} 20 real Tub (2.7CUFT)
<br />Cu Ft.
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<br />Z
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, PH
<br />WB31•- (Bio) /WP31— (Fath) /WC31— (Cheino) 31 Gal 'Sub (4.14:CU><T)
<br />Cu Ft.
<br />tj
<br />�
<br />6 N PG Regulated Medical Waste, n.e s,
<br />tuB43•- (sio) /Pki43-- (Fath)/cWd3— (Chino) teal Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o,s.,
<br />6.2, Pall
<br />KRB — Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n os,
<br />6 2, P611,
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />6.2, PGI)
<br />Cu Ft
<br />3. Gen tor's Certification: "I hereby declare that the contents of this consignment are fully and cu ly TOTALS I►
<br />Cu Ft.
<br />describe above by the proper shipping name, and are classified, packaged, marked and labelled If e , and
<br />are all speots In proper condition for transp rt according to applicable international and natio v n e re cations"
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<br />PORTER 1 ADDRESS. Phone 1866)783-7422
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<br />SteriCyole, Inc. ® This is a Through 8hipraent Applicable Permit Numbers:
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<br />4135 A. Swift Aire Hauler Reg# 3410
<br />2N
<br />Frevno,CA 93722
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<br />TRANSPORTS RTIFICA Receipt of dical waste as described ab
<br />M
<br />r'
<br />PrinMpe Name Signature Date
<br />5. INTERMEDIATE DL2 /TRANSPORTER 2 ADDRESS: Phone #.
<br />Nom„
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #
<br />Applicable Permit Numbers.
<br />N s a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />f —
<br />PdnVType Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />S-
<br />A. Doslgnatod Facility: [I 86. Alternate Facility. ® 8C. Alternate Facility: E] 8D. Alternate Facility.
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<br />Stedcycle, Inc. Stertcyt le, Inc. Stericycle, Inc.
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<br />4135 W. 5WIItAV6 90 N. Foxboro Drbm 1551 Shelton DrIve
<br />$ North Solt Lake. UT 84054 Hollister, CAA
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<br />i9��}3} Nie. 1I9.,5023
<br />':1'rif (866)783"7422 (866)783-7422
<br />(1368))783'742
<br />TS109TIA2 1 eii6sT 83
<br />AUG 2 2017
<br />TREATMENT FACILITY: I Certify that I have been authorized by the applicable state agency to
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<br />accept untreated medical wastes and that I have
<br />received the above Indicatecl wastes in accordance with the requirement outlined in that authorization.
<br />Print/rype Name Signature Date
<br />Transferred c:ontalners, ou ft to
<br />
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