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- — ^--- ---- - MEDICAL WASTE TRACKING FORM NUMBER
<br />p®® Ste ricyCle` CASE OF EMERGENCY CONTACT: CHEMTREG 1-800-424- STANDARD MANIFEST 001 -10 -06 -STD
<br />° PmtealnpPeoplo.Reducing Alse Route *: 123 - 22 CUSTOMER NO. 21132 M€IFROOJRGQ
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />1111111111
<br />GILL MEDICAL C)aN=
<br />1617 N CALIFORNIA ST
<br />SAN, CA 95204— 6117
<br />(2019) 451--9031
<br />10/3.0/2017
<br />CUSTOMER NUMaER 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OP WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />6.2, PGII
<br />TBOS 40 Gal Tub (Bio} (S.3 Cu ft}
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, mo.s.,
<br />TB49 - 37 Gal Tub (Biqa} (4.9 cu ft)
<br />6 2, PGII
<br />Cu Ft.
<br />iZ
<br />UN3291, Regulated Medical Waste, n.o.s.,9
<br />44 Gal Tub (Bio) (5 , 9 dd ft)
<br />� c
<br />®
<br />6 2, Pan
<br />Cu Ft.
<br />Q
<br />UN3291 Regulated Medlcai Waste, n,0 s.,
<br />Tn21- (SIo) /TptS- (Path) Tyi.5- tChemb) 20 tial Tub (2-7CUFT)
<br />CC
<br />6.2, PGII
<br />Cu F!
<br />W
<br />UN3291 Regulated Medlcai Waste, n,e.s.,
<br />WB3.t- (B3a) /NFQ31- (path) /WC31- (Llhemo) 31 Gal Tub (4.14CUFT)
<br />Z
<br />62, PGII
<br />Cu Ft.
<br />LU
<br />(3
<br />UN!, Regulated Medical Waste, n 0,s.,
<br />6.2, PGII,
<br />t
<br />wadi- (nio)/iau63- (Hath) /CW62- tchemo) teal 'Tub(5.7CUPT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />KRB — 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 />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®Cu
<br />Cu Ft.
<br />desc ed above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />an respecis in proper condition for transport according to applicable international and natlona rn I e ulatlone
<br />�Lt V1 U 1 WU I Y_6G�,1
<br />i Pr tad/Typed Name SI , e
<br />at
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<br />4. SPORTER 1 ADDRESS:
<br />Stericy0] e, Inc « This a 3 a Tittraugh Siri pmenlG
<br />Phone #. (866) 7B3-7422
<br />Applicable Permit Numbers:
<br />aYc
<br />alis W. SWiEt Ave
<br />Hauler Regi# 3400
<br />N
<br />Irrenno,CA 43722
<br />a Q
<br />a
<br />TRANSPORT CE TIM N: Receipt of medical waste as described
<br />CJ
<br />>-
<br />Date
<br />PrInVType Name Signature
<br />S. INTERMEDIATE HAN ER /TRANSPORTER 2 ADDRESS:
<br />Phone #
<br />C�
<br />Applicable Permit Numbers.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />w
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS`
<br />Phone #.
<br />}CCiI a
<br />>r Q
<br />Applicable Permit Numbers,
<br />w
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Q�s
<br />15
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INptCATION
<br />8A. Dastgnated Facility: 8B. Alternate Facility: ❑ 8C. Alternate Facility.
<br />❑ ED Alternate Facility:
<br />1e, Inc, swrlcycle, Inc. SterIcycle, Inc.
<br />Shabn Drive
<br />U
<br />4195 W. S1NtRAw SUN FoxbOra Dove 1681
<br />LL
<br />Fresno, _ ECWC4 Nodtt Set k ake, LII' 841154 Hollister, CA 95023
<br />(80783-7 22 (868)783-7422 (866)783-7422
<br />� � a 2017� 3a �T83
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<br />TREATMENT FA IT*Iertify that I have been authorized by the applicabmele state agency to accept untreated dical wastes and that I have
<br />the in that authorization.
<br />i-
<br />received aboaster accordance with the requirement outlined In
<br />PrintfType Name Signature
<br />Date
<br />TransfeMd M, di ft to
<br />'.T:TTl1� F
<br />
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