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e MEDICAL WASTE TRACKING FORM NUMBER
<br />fl ®Qt terwcycle® ASE OF EMERGENCY CONTACT: CHEMTREC 1.800-42 STANDARD MANIFEST 001.10.06-ST13
<br />Pre9cdlnpPe0P1e.ReJUt1"R1sk: Route : 123 — 14 CUSTOMER NO. 21132 MDFRQQJU2R
<br />ORIGINAL
<br />i. CaG'nt:raLAr'S IVaRlBr,p�lHg,�Ctr@SS 8Rq IeleJ3f10T1B 1VLIlT1Ol: t'
<br />Apfp: 1
<br />ATTN:
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<br />GILL MEDICAL CENTER
<br />1617 'N CALIFORNIA SS
<br />STOCKTON, CA 95204- 6117
<br />(209) 4S1-9031
<br />10/31/2017
<br />CUSTOMER NUMBER 6111852-001. GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2s. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medfcal Waste, n.o.s.,
<br />'1'Ba5 9Q Gal '�� (Bio} {5.3 Cu £t)
<br />CONTAINERS
<br />Cu Ft.
<br />6.2, PGII
<br />UN3291 Regulated MedlcalWasta, n,o,s„
<br />T1349 — 37 Cal Tub (Bio) (4.9 CU ft)
<br />Cu F1
<br />PC
<br />UN3291 Regulated Medical Waste, n,o,s,,lq
<br />6.2, PGII
<br />_ 44 Gall Tub (Hi�,o) (5.9 Cu ft)
<br />Cu Ft
<br />p
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T821— (BIO) TFIS— (Path) TY1S—(Chemo) 2 Gal T . CUFT
<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 />Z
<br />6.2, PGIE
<br />Cu Ft.
<br />6N3291 Regulated Medical Waste, n.o.s.,
<br />wgd3— (Bio) /Lxw63— (Pat h) /CW62- (Chemo) Gal Tub (S _ 7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, nas.,
<br />6.2, PGII
<br />AAB^ — Biosystems Cardboard Box (4.2 au ft)
<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 />L
<br />Cu Ft
<br />3. Generator's Certification: 'I hereby declare that the contents of this consignment are fully and accUr T®TALS ®
<br />Cu Ft.
<br />des b above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />a In all espects In proper conditjon for transport according to applicable International and nation vern ental regulations'
<br />t,ciryped Name ��fj � i hire
<br />ate y
<br />LDPr'
<br />N-TPASPORTER 1 ADDRESS:
<br />St;t3r�CliClt3 IRC. This is a Through Shipment:
<br />Phone N: (86 783-7422
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
<br />no.
<br />Fresno,CA 83722
<br />a Z
<br />TRANSPORT TIFIC 4 : Receipt of medical waste as describe
<br />3,�
<br />Print/Type Name Signature_
<br />Date
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />°eV s
<br />Applicable Permit Numbers:
<br />OU9
<br />�+
<br />r
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PrinV ype Name Signature
<br />Data
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #.
<br />Applicable Permit Numbers:
<br />r5
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printtiype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />6.
<br />Deelgnatod Fecillty: eB. Alternate Facility: ❑ 8C. Alternate Facility:
<br />8D. Altemate Facility:
<br />Stedcycle, Inc. Sbertcycle, Inc. Sberit ycle, Inc.
<br />a
<br />4135 W. &VMWE ORTIZ 80 N. Foxboro DrIvs 1661 Shelton DMA
<br />u-
<br />Fresno,CA 93722 North Sal Lake, UT 84054 Halllster, CA 95023
<br />1-886)783-7422
<br />(861'0)783-7422 (868)783-7422
<br />TWOST2��T 31 2017 3A�Iaa-mss TsIosTsa
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<br />TREATMENT FAGI04 'HY* that'l have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
<br />F
<br />received the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />Transferred contalnem, Ci ft to :
<br />4
<br />ORIGINAL
<br />
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