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MEDICAL WASTE TRACKING FORM NUMBER <br />• e <br />i ®i StQEI"1CyCle: CASE OF EMERGENCY CONTACT: CHEMTREC 1•800 -424 - <br />STANDARD MANIFEST 001 -10.06 -STD <br />®0 P.t"Iing P..pk Mdodr W$e Route #: 123 - 22 CUSTOMER NO. 21132 j+jj]F}7OO JP$Q <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOCKTO-N, CA 95204— 6117 <br />(209) 451-9031 <br />9/26/2017 <br />1-1185..00 <br />CUSTOMER NUMBERGENERATOR'S REGISTRATION# <br />2A. DESCRIPTION OEWASTE <br />213• CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., <br />TH05 - 40 Gal. Tub (Rio) (5.3 cu £t) <br />CONTAINERS <br />6.2, 1`1311' <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n,o.s,, <br />TU49 - 37 Gal TUt (Bio)(4.9) (4.9 au t <br />6.2, PGIjCU <br />Ft. <br />Ci <br />UN3291, Regulated Medical Waste, n.o.s, <br />']3l ' - 44 a Tub (Bio)(5.9) (5. 9 CU tt <br />® <br />6.2, PGII <br />Cu Ft <br />QUN3291 <br />Regulated Medical Waste, n.o.s., <br />` i <br />Cu Ft <br />tLLl <br />UN3291, Regulated Medical Waste, n.o.s., <br />tdS 1- B a WP31- (PaC3z WC31- {C3leiao} 3 Gal Tub (4.14GUFT <br />W <br />6.21 PGII <br />Cu Ft. <br />UNS2911 Regulated Medlcal Waste, n.o.s., <br />gQ _ (gy p} /pk149 (Spill} /C&lrtl3- (Chomp} pal Tub (5-7CUF`T) <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n o.s„ <br />M - Biosystems Cardboard Sax (4.2 cu it) <br />6.2, PGII <br />— <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.os., <br />6.2, PGif <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />Cu Ft. <br />ed, and <br />described above by the proper shipping name, and are classified, packaged, marked and labelledPre- <br />11 aspects in proper condition® for transport to applicable international and nationrnme re Mations;' <br />In tajcc(o�rding <br />�� " <br />pt to I �� <br />1 Prt ed/Typed Name `' V I u` �+ 11 y` " SI n611 <br />tr <br />SPORTER 1 DRE S• <br />eri cle Inc. 0 This 'is a Through Shipment <br />Phone #. -" <br />to <br />a <br />4135 W. Swift Ave <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />a Zresno,CA <br />93122 <br /><a <br />QM„ d <br />TRANSPORTS TI (CATSN: Receipt of medical waste as described ab a <br />Print/'type Name Signature <br />Date <br />5. INTERMEDIATE HANDLER12 / RANSPOR 2 ADDRESS. <br />Phone #: <br />fiq <br />Applicable Permit Numbers. <br />0�Q <br />m <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Print/Type Name Signature <br />Date <br />M <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. <br />Phone M <br />g <br />Applicable Permit Numbers. <br />owl ¢ z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />fE - <br />PdnVType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />~ <br />ted Facility: ❑ alt. Alternate Facility: ❑ 8C. Alternate Facility: <br />❑ 8D. Alternate Facility: <br />Sterlcycle, Inc. Stericycte, Inc. Sierlcycle, Inc. <br />4135 W. SWftAVe 90 N. Foxboro Drive 1651 Shelton Drtve <br />Fresno,CA 9 722 North Salt Lake, Lrr 84054 Hollister, CA 95023 <br />(8r, RM EO RM <br />(856)763-7422 (865)783-7422 <br />`i'SIOST22 3A -"8•,){'r-36 TSIOST 83 <br />SEP 2 6 2017 <br />W <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />t- <br />received the ab&#AWWed wastes in accordance with the requirement outlined in that authorization. <br />ay <br />Print/Type Name Signature <br />Date <br />