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p ® MEDICAL WASTE TRACKING FORM NUMBER <br />00 StericyCIe° OASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424* STANDARD MANIFEST 001.10 -06 -STD <br />V pmwina Poopia, Wudna MO. Route it 1.23 — 20 CUSTOMER NO. 21132 i'Ai}F' RlfVMC <br />R." <br />ORiGINAL <br />i. Generator's Name, Address and Telephone Number <br />`t`TZ+I e ;, <br />A 111111111111111111111111111111111111 <br />GILL MEDICAL CENTER, <br />1.61.7 N CALIFORNIA ST <br />sTOCt£TO'Nf CA 95204- 6117 <br />(20) 4514031 10/24/2017 <br />CUSTOMER NUMBER 6111852-00-1 GENERAxows REGISTRATION# <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINERTYPE <br />20. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, n.o.s., <br />TBOS - 40 Gal Tub (Bio) (5.3 cu ft) <br />CONTAINERS <br />6.2, PGIJ <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.os„ <br />TH49 - :37 G4LI TUU (SiO) (4.9 cu ft) <br />6.2, P81I <br />Cu Ft. <br />I= <br />UN3291 <br />2 p�lj Regulated Medical Waste, n,o.s., <br />TgI - 44 Gats Tuh (Bio) (S. 9 cu ft) <br />-r <br />Cu Ft. <br />Q <br />UN3291 ,Regulated Medical Waste, n.o.s„ <br />T821- (BSC?} TP15-;Path} TX1S- (Cliemx►} %"R Gal Tub (2.7CUFT) <br />cc <br />6.2, PGI! <br />Cu Ft <br />W <br />UN3291 -Regulated Medical Waste, n.o.s., <br />p831- (Rio) /WP31- (Fath)1WC31- (Cbeino) 31 Gal Tub (4.14CUPT) <br />6 2, PGIE <br />Cu Ft. <br />11Z <br />6 2. PH. Regulated Medical Waste, n.o s., <br />WB0- (Bio) /PK43- (Path) /Cw43- (Chetno) :Gal Tub (5.7CUFT) <br />Cu Ft. <br />6 23PGII Regulated Medical Waste, n.o.s., <br />MB - Biosystems Cardboard Box (4-2 cu ft) <br />Cu Ft <br />UN3291 Regulated Medical Waste, nos, <br />6.2, PGII <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.os., <br />6.2. PGII <br />Cu Ft. <br />ener or's Certification: "I hereby declaro that the contents of this consignment are fully and accurate) TOTALS ® ✓ <br />Cu Ft. <br />ibed Bove by the proper shipping name, and are classified, packaged, marked and labelled/pl and <br />re in all re pacts In proper condition for transport according applicable and natio ov tai regulations;' <br />jto�,international <br />&-a/ <br />t <br />Pr( edliyped Name � Ignatur <br />4. TR PORTER 1 ADDRESS: Phone #: (8 ) 78 3- 7422 <br />StericyC1.e` Iii1z!. This is a Through shipment <br />Applicable Permit Numbers. <br />cc cc <br />41.35 W. Swift Avie Hauler Regi 3400a <br />Fremno, CA 93722 <br />a s <br />TRANSPOR7E E TtFI ATI N cel I waste as described a <br />to <br />tr <br />Print/iype Name Date <br />5. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone #: <br />N <br />oar <br />Applicable Permit Numbers, <br />910 <br />a <br />cc <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />PrintrType Name Signature Date <br />x <br />S. INTERMEDIATE HANDLER 3 J TRANSPORTER 3 ADDRESS. Phone #: <br />a <br />w <br />Applicable Permit Numbers - <br />zsINTERMEDIATE <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />— <br />PrinVTypo Name Signature Date <br />7. DISCREPANCY INDICATION <br />y.Plleel <br />}�- <br />noted Facility: ❑ BB. Alternate Facility. E] SC. Altemate Facility: 0 so. Altarnate Facility: <br />otttft yclo, InQ. S'tettayele. Ilia. Sterlcoe. Inc. <br />v <br />4135 W. Sw,ig Ave 90 N. Foxboro Drive 1:;61 Shelton Drive <br />ILL .3 <br />G9 6�OMFORTix North Salt Lake, LTi 84= Hollister, CA 95023 <br />(866)783-7422 (866783-7420 <br />Ili <br />UWjTStdST22 <br />w®CT <br />3A -*1'i$ -„IA -35 TS10ST W <br />24 2017 <br />TREATMENT FACILITY: I certify that f have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the ajMWjpr�� ted wastes in accordance with the requirement outlined in that authorization. <br />Pr(nMpo Name Signature Date <br />R." <br />ORiGINAL <br />