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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />Q®®O CASE OF EMERGENCY CONTACT: CHEMTREC 1.600-q24 g STANDARD MANIFEST 007 -10.06 -STD
<br />Sterlicycie°
<br />° PtatednpPeople. Redu<I-iiRisk* Route #: 123 — IS CUSTOMER NO. 21132 MDFROOJQ8F
<br />1. Generator's Name, Address and Telephone'Number
<br />ATTN
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204— 6117
<br />(209) 451-9031
<br />10/3/2017
<br />CUSTOMER NUMBER 16111852-001 GENERATOR,s REGISTRATION 4
<br />2A. DESCRIPTION OFWASTE
<br />2r3. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />® 813. Alternate Facility: Fj 8C. Alternate Facility: 8D. Alternate Facility:
<br />UN3291, Regulated Medical Waste, n.o s ,CONTAINERS
<br />TBa5 — 40 Gal Tub (Bio) (5.3 cu ft)
<br />Stericycle, Inc. Stericycle, Inc.
<br />90 N. Foxboro Ct" 1661 Shelton Drive
<br />u`r-
<br />Fresno,CA 93722
<br />6.2, PGII
<br />rgs
<br />783- d2
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<br />Cu Ft
<br />a
<br />UN3291; Regulated Medical Waste, n.o,s.,
<br />TB49 — 37 Gal. Tub, (Bio) (4.9 Cu ft)
<br />Lu s
<br />�®
<br />TREATMENT F1fi&ft- rtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />6.2, PGiI
<br />PdntlType Name
<br />Cu Ft.
<br />CC
<br />UN3291 Regulated Medical Waste, n.o s,
<br />B14 :3)44 6a1 Tub(Bio) (5.9 cu tC)
<br />®
<br />6.2, PGA
<br />Cu Ft
<br />Q
<br />UN3291 Regulated Medical Waste, n o s,
<br />T021— (BIG) /TP15— (Patin) /TyIS— (Chemo) 20 dal Tub (2 _ 7Ci3FT)
<br />6 2, PGII
<br />Cu Ft
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />>WB31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal. Tub (4.14CUFT
<br />W6.2,
<br />PGII
<br />Cu Ft
<br />a
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />VE43_ (aio) /PW42— (Path) /CAt43-- (Chemo) (gat Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />62, PGII
<br />KRB— — Biosystems Cardboard Box (4-2 cu ft)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />I
<br />6,2, PGI
<br />Cu Ft.
<br />UN3291 ' Reoulated Medical Waste n.o.s.,
<br />6.2, 171311Cu
<br />Ft
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Cu Ft.
<br />d/ a deo, d
<br />as bove by the proper shipping name, and are classified, packaged, marked and labelleAc,
<br />re acts In proper c dilion for transport according to��aa%ppp' ca le International and narl,Im tat regulations"
<br />�[_iA, `^�'
<br />W=::
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<br />j Print dllyped NamCA
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<br />ORTER 1 ADDRESS:
<br />This is a Through Shipment
<br />#' (866) 783-7422
<br />Steric;yele, Inc.
<br />Applicable Permit Numbers:
<br />a o
<br />4135 A. Swift: Ave
<br />Hauler Reg# 3400
<br />0.
<br />Fresno,CA 93722
<br />CO
<br />IL Z¢
<br />TRANSPORTS TIFICATIQW�, ceipt of medical waste as described above
<br />PrinMpe Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone
<br />N
<br />S
<br />a
<br />Applicable Permit Numbers,
<br />.wo
<br />INTERMEDIA ANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Printrrype Name Signature
<br />c
<br />Date
<br />CO
<br />am
<br />8. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone k-
<br />5
<br />Applicable Permit Numbers:
<br />Win
<br />N to
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z�x—
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />eA. Designated Facility:
<br />® 813. Alternate Facility: Fj 8C. Alternate Facility: 8D. Alternate Facility:
<br />i
<br />ca
<br />Stericycle, Inc.
<br />4136 9V14W&M0R=
<br />Stericycle, Inc. Stericycle, Inc.
<br />90 N. Foxboro Ct" 1661 Shelton Drive
<br />u`r-
<br />Fresno,CA 93722
<br />North Sett Lake, ill' 84054 Hollister, CA 95023
<br />rgs
<br />783- d2
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<br />111,783-7422 (896)783-7422
<br />;A ss
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<br />TREATMENT F1fi&ft- rtify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />PdntlType Name
<br />Signature Date
<br />Transferred containers, cu !t to
<br />ORIGINAL
<br />
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