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<br />g, Stericyctes
<br />Protecting People, RcdWng Risk
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />QASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424- STANDARD MANIFEST 001 -10 -06 -STD
<br />Route #: 123 - 19 CUSTOMER NO. 21132 MDFRODJVII
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN.,
<br />GI14L MEDICAL CENTER
<br />1617 V CALIFORNIA ST
<br />STOCKTON, CA 96204-- 611.7
<br />(209) 451-9031
<br />11/7/2017
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />s.
<br />Ft.
<br />FL
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o
<br />61. PGII r.,, Ft
<br />3. Gorator's CerBffcation: "I hereby declare that the contents of this consignment are fully and
<br />dQsc�I d above by the proper shlpping name, and are classified, packaged, marked and label)
<br />rre in a1 es eels in propgr condition for tran port according t applicable international and Ion
<br />TVI I ,n/Oi N 7. 11 A%// /.1. 1 c
<br />TOTALS ►
<br />rc4. TRAtdSPORTER 1 ADDRESS:Phone #:(86151-783-7422Stericycle, Inc. [3 This a. rough Shipment Applicable Permit Numbers:
<br />a9335 W. Swift Ave Raul.ex Reg# 3400
<br />N Fremno, CA 93722
<br />a TRANSPO CER IFI ION: Receipt of medical waste as descnb ab o j —)-4 7
<br />~ PrinVtype Na Signature Date G 1
<br />CUSTOMER NUMlam 0111852-001 GENERATOR,s REGIS mioN#
<br />Phone t
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />Applicable Permit Numbers:
<br />UN3296 1
<br />, PI� Regulated Medicai Waste, n.o.s.,
<br />THOS — 40 Gal Tub (Bio) (5.3 cu ft)
<br />8 23291, Regulated Medical Waste, n.o.s.,
<br />TB49 — 37 Gal Tub (RiO) (4 � 9 Cu ft)
<br />O
<br />fi 2,3291 Regulated Medical Waste, n.o.s.,
<br />TH7 4 44 Gats Tub (Bio) (5.9 cu ft)
<br />Phone #:
<br />P011
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGi1
<br />Ts22i— (S3XO) /TP15— (Fath) /Tx1S— (chemo) 20 Gal Tub (2-7CUP'T)
<br />Z
<br />—
<br />Pr(nMpe Name Signature
<br />W
<br />Z
<br />UN3291 Regulated Medical Waste, n,os.,
<br />6.2, PGI
<br />NB31—(Bio)/WP31—(Path)/WC31—(Chemo)31 Gal Tub(4_14CUFT)
<br />�UN3291
<br />Regulated Medical Waste, n.o.s.,
<br />6.2, PG11
<br />wB43— (Bio) /L -W43— (Path) /CW02— (chemo) aal Tub (5.7CuFT)
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI1
<br />KRB -- Biosystems Cardboard sox (4.2 au ft)
<br />11/7/2017
<br />2C. NO. OF 12D. VOLUME
<br />CONTAINERS
<br />s.
<br />Ft.
<br />FL
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o
<br />61. PGII r.,, Ft
<br />3. Gorator's CerBffcation: "I hereby declare that the contents of this consignment are fully and
<br />dQsc�I d above by the proper shlpping name, and are classified, packaged, marked and label)
<br />rre in a1 es eels in propgr condition for tran port according t applicable international and Ion
<br />TVI I ,n/Oi N 7. 11 A%// /.1. 1 c
<br />TOTALS ►
<br />rc4. TRAtdSPORTER 1 ADDRESS:Phone #:(86151-783-7422Stericycle, Inc. [3 This a. rough Shipment Applicable Permit Numbers:
<br />a9335 W. Swift Ave Raul.ex Reg# 3400
<br />N Fremno, CA 93722
<br />a TRANSPO CER IFI ION: Receipt of medical waste as descnb ab o j —)-4 7
<br />~ PrinVtype Na Signature Date G 1
<br />elM
<br />Fresno.CA 93722 North Salt Lake. Lif 84054 Hollister. CA 951323
<br />(81516)(8 783-7�i22 (SM)783-7422
<br />fistras 7 201 7 3A 448,1A 36 MOST 33
<br />TREATMENT FACILITY: certify that t 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 />PriniMpe Name SignatureDate
<br />"r i+eaewlhs----8 — f { s
<br />ORIGINAL
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: L..f,! v
<br />Phone t
<br />W
<br />eP'
<br />Applicable Permit Numbers:
<br />o
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />a�
<br />o
<br />Applicable Permit Numbers:
<br />U)gz
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />—
<br />Pr(nMpe Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />8A. Designated Facility:
<br />8B. Alternate Facility:
<br />® 8C. Altemate Facility:
<br />E] 8D.Altemate Facility:
<br />U
<br />dCy ORT
<br />4135 W,
<br />Sisric _;Ia. Inc,
<br />90 N. Foxboro thrive
<br />Stericycle, Inc.
<br />15551 Shetlbn Drive
<br />elM
<br />Fresno.CA 93722 North Salt Lake. Lif 84054 Hollister. CA 951323
<br />(81516)(8 783-7�i22 (SM)783-7422
<br />fistras 7 201 7 3A 448,1A 36 MOST 33
<br />TREATMENT FACILITY: certify that t 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 />PriniMpe Name SignatureDate
<br />"r i+eaewlhs----8 — f { s
<br />ORIGINAL
<br />
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