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MEDICAL WASTETRXCK1Nb FORM NUMBER
<br />46.'* Stericycle` ISCASE OF EMERGENCY CONTACT: CHEMTREC i-800.424 STANDARD MANIFEST 001 -10 -06 -STI)
<br />Pretcclingft*PIe.AedudnpAllk Route #: 123 — 22 CUSTOMER NO. 21132 MDFROOJYUZ
<br />1l[2117italou Uut-IxaiineiS, Cil It iu
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL 14EDICAL CENTER
<br />1617 N CALIFORVIA ST
<br />SToc fToN, CA 95204- 6117
<br />(209) 451-9031
<br />12/5/2017
<br />CUSTOMER NUMBER 6111852-001 GENERATowsREOiSTRATION#
<br />2A. DESCRiPYION OF WASTE
<br />2131, CONTAINER TYPE
<br />20. NO. OF
<br />213. VOLUME
<br />UN3291, Regulated Medical Waste, n.a.s.,
<br />TB05 — 40 Gal Tub (Bi*) (5.3 Cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291Regulated Medical Waste, n.c.s.,
<br />TB49 — 37 Gal Tutt (Biro) (4, 9 cu ft)
<br />6.2, PGII
<br />Cu Ft
<br />M
<br />UN3291 Regulated Medical Waste, n.o,s.,
<br />TB14 — 44 Gal Tub (Bina) (5.9 CU ft)
<br />®
<br />6.2, PGII
<br />Cu Ft
<br />4
<br />UN3291, Regulated Medical Waste, n,o.s.,
<br />— (BIO) TP25— (Path) /TY15— (Chemo)Gal fi 2.7CUFT)
<br />6.2, PGII
<br />Cu Ft
<br />ui
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />WB31— (Bio) /WP31— (Path) /WC31— (Chemo) 31 Gal Tula (4.14CUFT
<br />6.2, PGII
<br />Cu R.
<br />!Z1!
<br />6 2329 Regulated Medical Waste, n.o.s.,
<br />WE43— (Sso) /I?W43— (Path) /cWd3— (Chemo) Gaal Tub (5.7CUFT)
<br />Cu R.
<br />6 2329, Regulated Medical Waste, n.c.s.,
<br />fC1�B _Biosystems 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 />UN3291Regulated Medical Waste, n.o,s.,
<br />6.2, PGiI
<br />Cu Ft.
<br />3. Generator's Certification:'1 hereby declare that the contents of this consignment are fully and accur ely TOTALS 0-
<br />. Cu Ft
<br />dese ove by the proper shipping name, and are classified, packaged, marked and labelieWplacarde
<br />/PoT n all acts In proper co ditlon for transport according to applicable Inter atlonal and nation a Ions"
<br />9a-
<br />{Pri ed/Typed Name 104
<br />SPOPTER 1 ADDRESS:
<br />St:ericy� le, Inc. This is a rough stripment
<br />Phone#. (866) 7$3-742
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<br />4135 W. Swift Ave
<br />AppElcabie Permit Numbers
<br />a
<br />Hauler Regi 34tX0
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<br />Fres�no,CA 93722
<br />RM
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<br />TRANSPORTS ERTIFICATIOceipt of medical waste as described abo
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<br />PrinM.Da Name Slgnature
<br />Date
<br />& INTERMEDIAT NDL /TR NSP TER 2 ADDRESS:
<br />Phone #
<br />N
<br />Applicable Permit Numbers -
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />Print/Type Name Signature
<br />Date
<br />tu
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />� �
<br />Applicable Permit Numbers:
<br />m a
<br />X
<br />INTERMERIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />fE—
<br />PrEnttlype Name Signature
<br />Date
<br />SC EPANCY INDICATION
<br />J;A.
<br />Dasignbted Facility., 8B. AItornato Facility: E] 8C, Alternate Facility: ® BD. Alternato Facility.
<br />cte, inc. Stedcycie, Inc. Stedcycle, inc.
<br />v
<br />4138 . SWR Ave 90 N. Foxboro Dt1ve 1551 Shelton Drive
<br />FresnQ,CA 93722 North Sat Lake, UT 84054 Hollister. CA SSD23
<br />(866)78jWEOR= (866)783-7422 (866)783-7422
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<br />TREATMENTtiiti�ILPr�: I fy that I have been authorized by the applicable slate agency to accept untreated medical
<br />wastes and that i have
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<br />received the above Indicated wastes In accordance with the requirement outlined in that authorization.
<br />ARWAm
<br />Prinveype Name Signature Date
<br />1l[2117italou Uut-IxaiineiS, Cil It iu
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