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<br />00 , S'�fL'ricyCle®
<br />®® Protenlnq hople.ReJadng Rick:
<br />OCASE OF EMERGENCY CONTACT: CHEMTREC 1 -800 -424 -
<br />Route #: 123 — 21 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001.10.06 -STD
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: it II III II f I f I I
<br />it I f f III I I it II f I
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNLA ST
<br />sTOCFTONr CA 95204- 6117
<br />(2091) 451-911731
<br />9/12/2017
<br />CUSTOMER NUMaER 611"1852-001 GENERATOR•s REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D, VOLUME
<br />UN3291, Regulated Medical Waste, n.os.,
<br />6.2, PGII
<br />TtOS — 40 Gal Tub (Bio) (5.3 C12 it)
<br />CONTAINERS
<br />Cu FL
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />_
<br />T049 37 Gal Tub (Bio) (4.9 Cu ft)
<br />Cu Ft.
<br />CC
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<br />UN3291, Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />Ti314 _ 44 1 Tub (Bio) (5.9 Cu ft)
<br />Cu Ft
<br />Q
<br />UN3291Regulated Medical Waste, n,o.s.,
<br />T1g21.- (BIC) /TPJ.5— (path) /TY15— (Chemo) 20 Gal Tub (2.7CUFT)
<br />a
<br />6,2, PGII
<br />Cu Ft
<br />LU Z
<br />62, PGII Regulated Medical Waste, n.o.s„
<br />X31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal flub (4.14CUFT)
<br />Cu Ft
<br />W
<br />62Regulated Medical Waste, n,os„
<br />, PGII
<br />W843— (sio) /PW43— (Path) /CW43— (Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />6.2, PGII
<br />KAB — Biosystems Cardboard Box (4.2 cu it)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />6,2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n,o.s„
<br />62, PGII
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurat ly T®YACs ®
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarde , and
<br />a spects In proper condition for transport according toapplicableInternational and nation o mental regulations"
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<br />Pri ad/Typed Name r SI Ur
<br />a
<br />T PORTER 1 ADDRESS:
<br />Phone # (866)783 422
<br />Stericycle, Inc. This is a Through Shipment
<br />Applicable Permit Numbers:
<br />a o
<br />4135 W. Swift; Ave
<br />Haulet: Reg# 3400
<br />n N
<br />Fcesna,CA 93722
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<br />TRANSPORT ERTIFIC : Receipt of medical waste as described above
<br />Ir
<br />Print/Typo Name Signature
<br />Date
<br />5. INTERMEDIATE NDLER 2 ! RANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />—
<br />PrinvType Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />m ¢
<br />�
<br />Applicable Permit Numbers,
<br />J
<br />a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Q�s
<br />F—
<br />Print/Type Name Signature
<br />Date
<br />T. DISCREPANCY INDICATION
<br />y
<br />F^'r
<br />8A. Designated Facility: 8R. Altornate Facility: 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />cgcle, Inc. Staricycle, Inc. Sterttycle. Inc.
<br />a
<br />4135 W. Wt Aw 90 N. Foxboro Drivel 1681 Shelton Me
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<br />Fresn North Salk Lake. LIT 84054 Hollister. OA 95028
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<br />(866)7 ' (866)783-7422 (866)783-7422
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<br />TSiOST22 � � Z ��+ $A -448 -JA -36 TSI+OST 83
<br />SEP
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<br />TREATMENT FA iLI Y: artily that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />In that
<br />Fes--
<br />received the i wastes accordance with the requirement outlined in authorization.
<br />Print/ijipe Name Signature
<br />Date
<br />'
<br />Transferred containers, cit 11 to
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