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MEDICAL WASTE TRACKING FORM NUMBER
<br />O is 5tericydev tN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424- 0 STANDARD MANIFEST cot-to-os-STO
<br />• Pratatln9People. ttedudngalei,; Route #: 123 — 23 CUSTOMER NO. 21132 MU11003MAJ
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />III1111111111111111111111111111111111111111111111111
<br />GILL MEDICAL Clai'ITER.
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451.-9031
<br />9/5/2017
<br />CUSTOMER NUMBER (5111852-001 GEN£RATOwsREGISTRATION #
<br />2A, DESCRIPTIONOFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />6.23291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGA
<br />T1305 — 40 Gal Tub {Bio} (5.3 Cil ft}
<br />CONTAINERS
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />9 _ 37l Tub {Bio} (4 , Cu i t}
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<br />6.2, PGII
<br />� l Tub (Bio) o} {5, g GLL fit}
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<br />UN3291, Regulated Medical Waste, n.o.s„
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<br />UN3291, Regulated Medical Waste, n,o.s.,
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<br />WB31- (Bio) /WP31- (path) INC31— (iClzeaao) 31 Gal Tub (4.14CUFT}
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<br />UN3291, Regulated Medical Waste, n.o.s,
<br />6.2, PGII
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<br />id843— {Bio) /P1N43— {path) /CfniG3— {Chemo) t3ttl Tub { ,. ?ei7F T)
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KRB — Biosystems Cardboard Box {4.2 cu ft}
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<br />UN3291. Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, n.c.s.,
<br />6.2, PGII
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<br />3, Generator's Certification-. 11 hereby declare that the contents of this consignment are fully and a ra TOTALS 110-
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<br />e by the proper shipping name, and are classified, packaged, marked and lab rde , and
<br />acts In pr perfour transport according tto appplicable In mational and na vern regu tions"
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<br />4.TRANSP TER 1 AbDRESS:
<br />Phone #:(8(59)-783-7422
<br />Stericycle, Inc. E] This is a Through Shiptaent
<br />Applicable Permit Numbers.
<br />a o
<br />4135 W. Swift it Ave
<br />Reg# 3400
<br />IL
<br />Fxesno,CA 93722
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<br />TRANSPORTE&MRTIFirATIPN?Ffecelpt o 1 waste as described above
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<br />PrinUlype Name Signature
<br />Date
<br />6. INTERMEDIATE NA LER 2/ TRANSPORTER 2 ADDRESS-
<br />Phone #:
<br />N�
<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
<br />Date
<br />„12
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone #:
<br />B cc
<br />Applicable Permit Numbers -
<br />C) s 1o
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
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<br />PrfnUType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Designated Facility; 86. Alternate Facility: 8C. Alternate Facility: 8D, Alternate Facility:
<br />S cle, Inc. Stericycle, Inc. Stericycle, Inc.
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<br />�4t36 Sw UVO 90 N. Foxboro Drive 1551 Shelton Drive
<br />M.Frea
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<br />a ^X12 North Salt Lake, IIT 84064 Hollister, CA 95023
<br />(866) 12')
<br />(866)78"422
<br />(866)�783t�-,7,
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<br />SEP 5 2017
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the cjhbYa',3D¢Ibated wastes in accordance with the requirement outlined In that authorization.
<br />PrinMpa Name Signature
<br />Date
<br />0 Transferred containers, cu ft to:
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