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i MEDICAL WASTE TRACKING FORM NUMBER
<br />1901► Ster,CyCRci" ISCAS9 OF EMERGENCY CONTACT: CHEMTREC 1-800.4240 STANDARD MANIFEST 001.10-06-STO
<br />e '..CilnyPeopleRedudni;114 Route fps 123 — 15 CUSTOMER NO. 21132 MDFROOJOAH
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<br />OR(GiNAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MZDICAL CENTER
<br />1617 N CALIrORNIA ST
<br />S=TON, CA 95204- 6117
<br />(209) 451-9431
<br />9/19/2017
<br />CUSTOMERNumsER 6111852-001 GENERATOR'sREGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBOS — 90 Gal Tub {Bio) (5.3 cu €t)
<br />CONTAINERS
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s„
<br />TBA 9 — 37 Gal Tub (Bio) (4.9 cu ft)
<br />6.2, PGII
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<br />6 23229r11i Regulated Medical Waste, n.o.s.,
<br />TB3 q 44 Gal Tub (Bio) (5.9 cu t:t)
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<br />Cu Ft.
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<br />UN3291, Regulated Medical Waste, n.os.,
<br />TB21— (Bia)TP15— {path} TY15— (Chemo) 20 Ga Tu (2.7cUFT)
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />WB31— (Bio) /WP31•- (Path)/WC31— (Chemo) 31 Gal Tub (4.14CUFT
<br />Z
<br />6.2, PGII
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<br />UN3291 Regulated Medical Waste, R.o.s.,
<br />6.2, PGII
<br />wEd3— (Sits) /piid43— (Path} /cw43— (Chemo) Gal Tub (5.7CUFT)
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<br />6 23PGI� Regulated Medical Waste,
<br />KREI— Biosystems Cardboard Box (4.2 cu £t)
<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 />6.2, PGII
<br />Cu Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®rA{-S ®
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<br />described above by the proper shipping name, and are Classified, packaged, marked and labelled/ ed, and
<br />ar espects in proper condition for transp rt according to applic a international and naElo ai mental regular
<br />1Prin drryped Name `-' Si re
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<br />A.T PORTER 1 AbDRESS:94.�66)
<br />St:ericycl.e, Inc. ® This is a Through"ErLiptuent
<br />783-7422
<br />Applicable Permit Numbers -
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
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<br />E'resno,CA 93722
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<br />TRANSPORTE"TIFICAMW. Receipt of medical waste as described o
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<br />PrintlType Name Signature
<br />t
<br />Date
<br />5. INTERMEDIATE HANDLER12 /TRANSPORTER 2 ADDRESS:
<br />Phone ff
<br />o`vGsm
<br />Applicable Permit Numbers:
<br />Rmo
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />PrinVType Name Signature
<br />Date
<br />ip
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #.
<br />Applicable Permit Numbers,
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVType Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />A. Designated Facility; [j SB. Alternate Facility: E3 ac Altemate Facility: ❑ 8D. Alternate Facility:
<br />1
<br />S Ycle, Inc. Stedcycle, Inc. Stericycle, Inc.
<br />4136 W. SWftAVO 80 N. Foxboro Drive 1551 Shahan Dries
<br />SK
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<br />Fresno,CA 93722 North Sall: Lake, UT 84054 Hollister, CA 95028
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<br />T�_ 7§183- r^fAiIZ (886)783-7422 (866)783-7422
<br />, 3A -448,W36 MOST 83
<br />cc
<br />cc
<br />TREA �f iTI�I�R'r�; f 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 />receive e((}}above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/fype Narfte��s>- Signature
<br />Date
<br />rransterred containers, cuff to :
<br />OR(GiNAL
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