|
MEDICAL WASTE TRACKING FORM NUMBER
<br />�. p teric cle' ASE OF EMERGENCY CONTACT: CHEMTREC 1-600-424 STANDARD MANIFEST 001 -10.06 -STP
<br />• ProteetingPeople. Reducing Al,k' Route #a 123 — 24 CUSTOMER NO. 21 2 MDFROQKILAr
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />I
<br />GILL MEDICAL CENTER.
<br />1617 N CALIFORNIA ST
<br />STOMTO.Of CA 05204— 61:0
<br />(04) 451--M31 12/26/2017
<br />CUSTOMER NUMBER 611-1852-001 GENERATOR'S REGISTRATION #
<br />2A, DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />20. NO, OF
<br />2D. VOLUME
<br />UN3291 'Regulated Medical Waste, n.o.s.,
<br />T'BQS — �!a Call Tt�fj (81 ta) (S.3 t tl it)
<br />CONTAINERS
<br />Ft.
<br />6.2, PGII
<br />Cu
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGi)
<br />TB49 — 37 Cal Tub (Biro) (4-9 ,:rix xt)
<br />Cu Ft.
<br />CC
<br />03291 'Regulated Medical Waste, n o.s ,
<br />TB14 49 Gal Ttt13 tB3 ir) (S . Ot} t}
<br />t
<br />Cu Ft.
<br />6.21 PGII
<br />4
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB21— (Bx(3) /TPJ.5— (Pa1=h) f TYiS— (Chemo) 2t! tial Tuts (2.70UF
<br />)
<br />CC
<br />6.2, PGII
<br />Cu Ft.
<br />f1!
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />W93.1— (Bio) /WP31— (Pada) /WC31— (Cheano) 31 Gal TUD (4.14CU
<br />T)
<br />Z
<br />6.2, PGII
<br />Cu Ft.
<br />LIj
<br />UN3291 Regulated Medical Waste, n o.s.,
<br />6.2, PGII
<br />RIgt13— (Sio)/>?2t03— (i ak3a) f Ctrt43— (Chemo) teal Tub(5.7CUPT)
<br />Cu Ft
<br />UN329i ,Regulated Medical Waste, n.o.s„
<br />6.2,, PGEI
<br />Cardboard Bax (4.2 au ft)
<br />KRB_ — Biosysttemsar
<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, PGI{
<br />Cu Ft.
<br />�f
<br />3. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TtaTALS ® /
<br />Cu Ft.
<br />bove by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />dCintedMpad
<br />spects In proper condition for transport according to applicable international and national ver mental regulations"
<br />Name/�- SI
<br />RANSPORTER i ADDRESS, Phone #: (866) 783-7422
<br />StericyCle, Inc. This is a fiFarottgii shipment Applicable Permit Numbers:
<br />a o
<br />4130 W. Swift Ave Eaulet: Reg# 3400
<br />M M
<br />E'renno, CA 93722
<br />U)
<br />Q
<br />TRANSPORTER:CER� IFIL IO : ipt of medl waste as described abo 1
<br />~
<br />Print/Type Name Signature Date
<br />5. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone #.
<br />N
<br />�15�
<br />Applicable Permit Numbers:
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/lype Name Signature Date
<br />M
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone M
<br />Applicable Permit Numbers
<br />Za
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above,
<br />PrinVtype Name Signature Date
<br />7. DIS EPANCY INDICATION
<br />}
<br />8A. Doslgnated Facility: Ll 8B. Altemato Facility: ❑ 8C.Altemato Facility: ❑ 8D. Altemate Facility:
<br />t�eit�yaltt St daycte, Inc. stericycle, Inc.
<br />.A
<br />W
<br />I-
<br />4135 9Q N. Foxboro Dove 1551 Shetton Dove
<br />Fre A 937 North Salt Lake, UT &1054 Hollister, CA 95023
<br />- 3-7422
<br />Z
<br />(865)783-7422 (896)783-7922
<br />16ST2,fO
<br />3A -448 -JA 36 TSIOST 83
<br />TREATMENT FACILO: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />P
<br />received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />I,,,
<br />rande—irred eontaiters, Cu ft to
<br />ORIGINAL
<br />
|