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®°i• Stericycle'
<br />° AIDWIR9 NCO-. RedOng RRk
<br />SASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-0
<br />Route #: 123 — 21 CUSTOMER NO. 21132
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10.06 -STD
<br />MnIt'nnf-t G.ns V
<br />rs i YSCAi wmim i rAaunti 1k me*mp'tnat i nave been autnorized by the applicable state agency to accept untreated medical wastes and that I have
<br />h recelved the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/type Name
<br />Transferred
<br />containers,
<br />ORIGINAL
<br />Date
<br />1. Generator's Name, Address and Telephone Number
<br />GILL MEDICAL CEitiUM
<br />1617 N CALIFORMA ST
<br />STOCKTON, CA 95204- 6117
<br />Pfla)
<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />11W CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />CONTAINERS
<br />6.2, PGI
<br />q _ a
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB49 — 37 Gal Tub Mies 4.9 Cu 1%
<br />Cu Ft.
<br />W
<br />UN3291 Regulated Medical Waste,
<br />,
<br />®
<br />6.2, PGd
<br />4 -- 44 Gal Tub (Hia , 9 CU tt
<br />!
<br />S / Cu Ft.
<br />CC
<br />UN3291 Regulated Medical Waste, n.ox,,
<br />6.2, PGII
<br />TB2.t— (BIO) /TL'15-- (Bath) /TY15— (Chemo) 20 Gal Tub (2 - 7CUFT)
<br />Cu Ft.
<br />iii
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGI1
<br />WR31—Bio WP31— Bath WC31— Chelna 31 ,Gal Tub 4.14CUPT
<br />Cu Ft.
<br />ttZ�
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI
<br />,r r
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGI
<br />Rom ailCu
<br />Ft.
<br />UN3291 Regulated Medical Waste, n.D,s.,
<br />6.2, Pk,,
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.D.s.,
<br />6.2, PGI
<br />Cu Ft.
<br />3. Generator's Certification: 9 hereby declare that the contents of this consignment are fully and accurately TOTALS ® 7Tr- Cu Ft.
<br />described abovey the roper shipping name, and are classified, packaged, marked and labelledlplacarded, and
<br />are In all respects in pr, orc ndltlon for transport according to ap able international and national governor regulations °
<br />V�\ ( 4�`' - l z
<br />gn-zb
<br />!PrintedlType eine at Date` /
<br />4. TRANSPORT 1 ADDRESS: hone #:
<br />(8 66 ,8 2
<br />Ni m ers:
<br />St:ericycle, Inc. u This i s rough Shipmeat Applicable Perini ere:
<br />a a
<br />4135 W. Swift Ave Hemet: Re}g# 3400
<br />in
<br />Fcesneo,CA 93722
<br />a. a
<br />TRANSPORTER CERT FICATION: Receipt of medical waste as described ab e
<br />~
<br />{{ j
<br />o'J21 Eq 1��
<br />� �
<br />Pdnt/lype Name Signature Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #.
<br />N
<br />Applicable Permit Numbers.
<br />O
<br />R
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />—
<br />PrinMpe Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone C
<br />Few
<br />Applicable Permit Numbers:
<br />0.20
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />x
<br />—
<br />PrtnV7ype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />}e
<br />. Designated Facility:
<br />e9. Alternate Facility:
<br />E] BC. Alternate Facility:
<br />8D. Alternate Facility:
<br />—'
<br />Stericycle, Inc.
<br />W. Sft
<br />Sterlcycle, Inc.
<br />SUrIcycle, Inc.
<br />a
<br />4135 tAve
<br />80 N. Foxboro Drive
<br />1551 Shelton Drive
<br />u-
<br />Presno.CA 13722
<br />North Salt Lake, UT $4054
<br />Hollister. GA 95023
<br />1-
<br />(886)783-74&WNEt3t
<br />(8 )783-7422
<br />(85)783-7422
<br />TIMPT A?
<br />Q
<br />s,rn n �)n17
<br />rs i YSCAi wmim i rAaunti 1k me*mp'tnat i nave been autnorized by the applicable state agency to accept untreated medical wastes and that I have
<br />h recelved the above Indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/type Name
<br />Transferred
<br />containers,
<br />ORIGINAL
<br />Date
<br />
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