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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />ASE OF EMERGENCY CONTACT: CHEMTREC 1.900-424 STANDARD MANIFEST 001-10.06-STO
<br />Route # 123 — 15 CUSTOMER NO. 21132 MDJk ROOJVZN
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: II li lil ii II li l l
<br />I l it iii li i 11 I
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204— 6117
<br />(209) 451-9031
<br />11/14/2017
<br />CUSTOMER NUMBER 6111852-001 GENERATOR'S REGISTRATION#
<br />2A. DESCRIPTION OF WASTE
<br />2H. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TBQS — 40 Gal. Tub (Bio) (5.3 cu it)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n o s.,
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu 'It)
<br />6.2, PGI)
<br />Cu Ft
<br />Regulated Medical Waste, n.o.s.,B14
<br />44 Gal Tub (Bio) (5. 9 cu ft)
<br />®UN3291,
<br />6,2, PGII
<br />t Cu Ft
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB21— (BIO) /TP15— (Path)TY15— (Chemo) tis eal Tt&(2.7CUFT)
<br />91
<br />6,2, PGII
<br />Cu Ft.
<br />W
<br />U143291 Regulated Medical Waste, n o s,
<br />WB31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4.14CUFT
<br />Z
<br />6,2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />6.2, PGII
<br />vu43— (Bio) /PWaa— (Path) /CW43— (Chemo) Gal Tub (5.7CttFT)
<br />Cu Ft
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />IRB „ BiG stems Cardboard Box (4.2 cu ft)
<br />�
<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 T®TAI_S lllp�
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<br />des6 above by the proper shipping name, and are classified, packaged, marked and labelled/ ac ed, and
<br />'
<br />In all spects in proper co ditlon for transport accord' to applicable lternational and n n ove ment re lations:'
<br />814-
<br />f P tedlTyped NameLI Signatur
<br />Date
<br />a
<br />NSPORfiER 1 ADDRESS:
<br />This augh Shipment
<br />Phone C (8 66) 783-7422
<br />Stericycle, Inc.
<br />Applicable Permit Numbers.
<br />4135 V. Swift Ave
<br />Hauler Reg# 3400
<br />n aa.
<br />FcetsnO, CA 93722
<br />to
<br />Q
<br />TRANSPORT RTIFICATIO : Receipt of medical waste as descnbe
<br />Print/Type Name Signature
<br />Date ( F
<br />S. INTERMEDIATE HANDLER /TRANSPORTER 2 ADDRESS.
<br />Phone #.
<br />a
<br />0g111i
<br />Applicable Permit Numbers
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Print/Type Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone #:
<br />Applicable Permit Numbers
<br />N M 2
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />lgnated Facility: [� 8t3. Alternate Facility: 8C. Alternate Facility,
<br /><rlcycte,
<br />08D. Altemate Facility:
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<br />Inc. Stericycle. Inc. Stsricycle. Inc.
<br />4136 W, Stisvnt Aw 90 N. FoxDaro t'h'us 1661 shettan Dftw
<br />I—'-
<br />Preenu,CA 33 E C Nora( Sett Lance. UT 843�i Hollister CA 96023
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<br />(855)783-7d (866)783-7422 (8&61784-T�122
<br />TSIOST22 3A -448 -JA -36 TSIGIST 83
<br />NOV 14 2i7
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />F—
<br />received the above indite s in accordance with the requirement outlined in that authorization.
<br />Print/T'ype Name Signature
<br />Date
<br />C
<br />Cans effe co ers, Cif ft to
<br />ORIGINAL
<br />
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