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<br />• hotectinghople.Oduefoglesk:
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />OASE OF EMERGENCY CONt'ACT: CHEMTREC 1-800-420 STANDARD MANIFEST 001.10.06-STO
<br />Route #: 123 – 25 CUSTOMER NO. 21132 MDFROOK212
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<br />Transferred containers, eu R to =
<br />1. Generator's Name, Address and Telephone Number
<br />1111111111 Pill1111111111111
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 481--9031
<br />1/2/2018
<br />CUSTOMERNutAaER 6111 852-001 GENERATows REusTRAnoN 41
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s„
<br />612, Poll
<br />'TB05 – 40 Gal Tub (Si.o) 0.3 cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291 ' Rogulated Medical Waste, n.o.s.,
<br />6,2, PGII'
<br />TI349 - 37 Gal Tub (Bio) (4-9 CU •et)
<br />Cu Ft.
<br />I=
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, 1`611Bl4
<br />44 Gal Tub (Bio) (5.9 cu 1;t)
<br />Ft.
<br />QCu
<br />23291 Regulated Medical Waste, n.o.s.,
<br />TB21•- (BIO) /TP1S- (Path) /Tris– (Chemo) 2O tial Tub (2.70UFT
<br />C".
<br />fi
<br />Cu Ft.
<br />W
<br />Z
<br />UN3291Regulated Medical Waste, n o,s.,
<br />6,2, PGIl
<br />WB31– (Ri.o) /WP31– (Path) /WC31– (Chemo) 31 Gal Tub (4.14CUF)
<br />Cu Ft.
<br />tJI
<br />Ch
<br />6.2 2P9G11� Regulated Medical Waste, n.o.s.,
<br />t+iB43– (Bio) /PW43– (Path) /CW43– (Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291Regulated Medical Waste, n.o.s.,
<br />6.2, PGIf
<br />KRB – BjoEystems Cardboard Box (4.2 cu ft)
<br />Cu Ft
<br />U143291, Regulated Medical Waste, n.o.s.,
<br />6.2, PSi)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGIi
<br />Cu Ft.
<br />3. Generator's Cartiflcatlon: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Cu Ft.
<br />desp above by the proper shippping name, and are classified, packaged, marked and label rded, and
<br />ar !S"al[ spects in proper co iffon for transport according to applicable International and atio Pgo rnmen e latfons"
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<br />2— I
<br />i P ted/iyped Name Signature
<br />SPORTER i ADDR Ss:
<br />Ph ne #: ($66) 783-7422
<br />Stericycle, Inc. U Tttis is a Through shipmeni:
<br />Applicable Permit Numbers:
<br />92
<br />4135 W. Swift: Ave
<br />Bauler Reg# 3400
<br />N
<br />Frenno,CA 93722
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<br />TRANSPORTS TIFIC TI ecelpi of medical waste as describ
<br />l;�
<br />PrinVWpo Name signature
<br />Date
<br />S. INTERMEDIATE RANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/fype Name Signature
<br />Date
<br />`w
<br />8. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />aApplicable
<br />Permit Numbers:
<br />y
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />–
<br />Printllype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />SA. Doaigna d Facility: ea. Alternate Facility; ❑ 8C. Alternate Facility [, 8D. Alternate Facility:
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<br />Stericycle, inc. Stericycle, inc. Stericycle, Inc.
<br />4136 W.Swl Ye 80 N. Foxboro Drive 1661 Shelton Drive
<br />Fresno,CA 9,g North Salt Lake, LIT 84054 Hollister, CA 95023
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<br />(866)783-74'2 (866)783.7422 (866)7M7422
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<br />TWOSTWIk 3A -416 -JA -36 TStOST83
<br />TREATMENT iCiL�f� ify that I have been authorized by the applicable state agency to accept untreated that I have
<br />i"
<br />medical
<br />received the abo dicat+astes in accordance with the requirement outlined in that
<br />wastes and
<br />authorization.
<br />PrinUTypa Name d Signature
<br />Date
<br />I
<br />Transferred containers, eu R to =
<br />
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