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<br />SE OF EMERGENCY CONTACT: CHEMTREC 140(1.424•
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<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10 -08 -STD
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:111111111111111111111111111111111111111111111111111111111
<br />GILL MEDICAL GENZER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(249) 451-9031
<br />11/28/2017
<br />CUSTOMER NUMBER 6111852-00-1 GENERATows REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />T805 — 40 tial Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB _ 37 Gal T� (Bio) (4.9 cu Lt)
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<br />UU232291, Regulated Medical Waste, n.o.s.,
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<br />44 Gal Tub (Bo) (5.9 Cu ft)
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<br />UN3291,RegulatedMedicalWaste,n.o.s_,
<br />Tg21-(BSO),/TP15_(Pethy/.TX15-.(Chemo)20-Sal Tub(2.ICIJFTy
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<br />UN3291, Regulated Medical Waste, n.o.s-,
<br />6.2, PGII
<br />WB31- (Bio) /UP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUF?
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<br />UN3291, Regulated Medical Waste, nas.,
<br />6.2, PGII
<br />u943—(Bio)/PW43-(Path)/CV43-(Chemo) tial Tub(5.7CUIFT)
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />tIIiB — Biosystems Cardboard Box (4.2 cu it)
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<br />UN3291, Regulated Medical Waste, n.a.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />3. G rator's Certification: 'I hereby declare that the contents of this consignment are fully and urately T®TALS ®
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<br />d ribe above by the proper shipping name, and are classified, package marked and labelle c rid
<br />spects in proper condition f/ojj�tran rt ccording to applicable rnational and n ntaf regulations"
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<br />ANSPORTTER 1 ADDRESS:
<br />Phone #: (B66) 783-7422
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<br />Stericycle, Inc. This is a Through shipment
<br />Applicable Permit Numbers:
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<br />4135 W.. Swift Ave
<br />Hauler Reg# 3400
<br />MCL
<br />Fresno,CA 93722
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<br />TRANSPO C RTIF A eceipt of ical waste as descri a
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<br />Print/Type Name C 12 Signature
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<br />Date
<br />5. INTERMEDIATE HANDI-01 i ITR NSPORTER 2 ADDRESS:
<br />Phone M
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone 4:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Printfrype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />8A. Designated Facility: Se. Alternate Facility: 8C. Attemats Faculty:
<br />8D. Alternate Faculty:
<br />Stericycle. Inc. 917 &ycie. Inc. Vmdcycie, Inc.
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<br />4135 W. StMlt AV$ SO N. FMdWM DMG 1551 Shelton Drive
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<br />Freano.CA 93722 Norlit Salt Lake, UT 84M4 Hollister. CA 2=3
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<br />(866)783-7422 (666)783-7422 (8M763-7422
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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 1 have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
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