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MEDICAL WASTE TRACKING FORM NUMBER <br />®®®tericyCle° CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-4246 STANDARD MANIFEST 001 -10 -06 -STD <br />°•® p,olecftPeopte.Q.dnyklsk.' RO�it e 0. 123 — 22 CUSTOMER NO. 21132 MUR003 LtH3 <br />;t ORIGINAL <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N CALI1! OR.1�2i��T <br />STOcKTalle GA fi L'17 <br />(209) 451--9031 <br />3/29/2017 <br />6111852-001 <br />CUSTOMER NUMBER GENERATOR'S REG{STRATTON # <br />2A. DESCRIPTION OF WASTE <br />213. CONTAINERTYPE <br />20. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medltal Waste, n.o.s., <br />TEUa — 40 Gal Tub (Bio ) (5.3 cu. it) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, mos., <br />6.2, PGij <br />TIJ4 J7 Gal—TUTVA?''u <br />Cu Ft. <br />IY <br />UN3291 Regulated Medical Waste, n,os,, <br />Y`814 44 Gall r1'u1a (r11.rt ) ts.9 Cu. t <br />® <br />6.2, P1311., <br />Gu ! t. <br />I" <br />Q <br />UN3291, <br />Regulated Medical <br />a a <br />23PGU <br />Cu FL <br />LU <br />U6.23291 Regulated Medical Waste, n <br />'-.o.s., WB31(Bio)/WP31— (Pati b) /WC31— {chemo} 31 Gal Tub t4.14CUFT) <br />Z <br />Cu Ft <br />LU <br />UN3291 Regulated Medical Waste, n.o.s., <br />ytgg3_ tgio} jpfaC3_ (gath}/calci—(Chemo} Gal Tct1� (5.7CtJFx) <br />6.2, PGIi <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />YaB — Biosystems Cardboard Box (4.2 cu its <br />6.2, PGij <br />-- <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.os., <br />6.2, PGII <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s„ <br />6.2, PGIj <br />F0 Cu Ft <br />3. Genn tor 'aCertification: "I hereby declare that the contents of this consignment are fully and accur tely 7®TALS ® <br />Cu Ft <br />d d ova by the proper shipping name, and are classilied, packaged, marked and labelledtplaca ed, <br />re in all re ects In proper condition for transport according to applicable International and nau an I regulations" <br />i <br />�.tind_ \)Jt���.�G;2tj— <br />Prin yped Name <br />CC--zg� <br />J. T ORTER 1 ADDR9SS: <br />Steraeycle, Inc. This is a Through Shipment <br />Phone # <br />9- t" <br />W. Swift Ave <br />Applicable PerNumbers: <br />HRauler eglst 34011 <br />N4135 <br />I te�no, CA 93722 <br />nom. q <br />TRANSPORTS TIFICATI eceipt of dlcat waste as describe ve. <br />2 <br />Printlrype Name Signature <br />Date <br />6. INTERMEDiATE HANDLER i ANSPORTER 2 ADDRESS: <br />Phone #: <br />sApplicable <br />Permit Numbers- <br />u' <br />a <br />y x <br />INTERMEDfATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />— <br />Prtntlrype Name Signature <br />Date <br />M <br />a <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Permit Numbers: <br />¢ x <br />ui <br />Applicable <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />_ <br />PrInMpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />rr <br />} <br />8A. Designated Facility: 68. Alternate Facility: E] ac. Alternate Facility: <br />8D. Alternate Facility: <br />3 <br />i- <br />terra Ie, Inc, &tafi%mle, Inc. Surlgmle, Inc- <br />413 SWft Aw 50 N. Foxboro Drive 1681 Shelton Drive <br />< <br />Fr6� 8 �tTleK North Salt Lake, UT 84054 Hollister, CA 955023 <br />(866)783-7322 (866)783.7422 (866)783-7422 <br />LU <br />TWOS= -3A-448-JA-36 TS/0S -W <br />aAUG <br />� <br />29 2017 <br />TREATMENT' FACIE TY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have <br />TY: <br />h <br />received thettlI re wastes In accordance with the requirement outlined in that authorization. <br />Print/Type Name Signature <br />Date <br />Transferredcontainers, CU ft to <br />;t ORIGINAL <br />