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MEDICAL. WASTE TRACKING FORM NUMBER
<br />+®i® 'teric C'e' SE OF EMERGENCY CONTACT: CHEMTREC 1-800424-M STANDARD MANIFEST 001 -10 -06 -STD
<br />"T., a �: 123 - 15 CUSTOMER No. qrMDFROOJS50
<br />1 trditbil"r i�Ab� W U am .
<br />101 14IM
<br />1. Generator's Name, Address and Telephone Number RolI
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CALWORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031
<br />10/17/2017
<br />CUSTOMER NUMBER 61-11852-001 GENERATOR's REGISTRATION A
<br />2A, DESCRIPTION OF WASTE
<br />2B• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBp5 — qp Gal Tub (Rio) (5.3 cru ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB49 — 37 Gil TUb MO) (4. 9 Cu ft)
<br />6.2, PGII
<br />Cu Ft.
<br />Cr
<br />Regulated Medical Waste, n.o.s.,
<br />81 44 Gil `tub (Dio) (5.9 Cu ft)
<br />®
<br />6.2, PGII
<br />a Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.c.s.,
<br />?921- (BSO)TP15- (Path)TYSS- (Chemo)20 Gal Tub(2.7CUPT)
<br />6.2, PGII
<br />Cu Ft.
<br />W
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />WE (Bio) /WP31- (Path)/WC31- (Chemo) 31 Gal Tub(4.14CUFT)
<br />6.2, PGII
<br />Cu Ft.
<br />IU
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />W263- (9io) /Pw63- (Path)/CW63- (Chemo) Gal Tub (S.7CUFT)
<br />Cu Ft.
<br />623 PG" Regulated Medical Waste, n.o.s.,
<br />KRB — Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Fl,
<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 �►
<br />Cu Ft.
<br />ed above by the proper shipping name, and are classified, packaged, marked and labelled/placarde
<br />re in respects in proper condition for transport according to applicable international and natio mental regulatio
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<br />Pr" ed/Typed Name ature
<br />SPORTER 1 ADDRESS:
<br />Phone tt: (B W783-7422
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<br />Steci�le, Inc. This is hrOugtt f9klipme111t
<br />Applicable Permit Numbers:
<br />4135 V. Swift Ave
<br />Hauler Reg* 3400
<br />M �
<br />FCeano,CA 93722
<br />Fr
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<br />TRANSPORTER ERTIFICATI •'t eceipt of medical waste as descri abov
<br />PrinUType Name Signature
<br />Date
<br />5. INTERMEDIATE 9XI115LER 2 / TRA PORTER 2 ADDRESS:
<br />Phone p:
<br />Applicable Permit Numbers:
<br />w
<br />I�u a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone tf:
<br />VR w
<br />Applicable Permit Numbers:
<br />MJ
<br />W M a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />F —
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility: 86, Alternate Facility: 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />M
<br />)$ A: tE QRZ Ina. Ste bic.
<br />1W111ho DrMe
<br />4135 W. $MR Ave SO N. �tl Drive b n
<br />Fresno CA 93722 North Sa{t Lake, tti Holfter, CA 95023
<br />- 1 2417 (MM3 -7422 � 422
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<br />ST 83
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated
<br />medical wastes and that I have
<br />Fes•
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Printlrype Name Signature
<br />Date
<br />1 trditbil"r i�Ab� W U am .
<br />101 14IM
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