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:'•® Stericycle• <br />• PwIt dinpP•opid Repudnp94 <br />MEDICAL. WASTE TRACKING FORM NUMBER <br />ASE OF EMERGENCY CONTACT. CHEMTREC 3.80042 STANDARD MANIFEST 001.10.06 -STD <br />Route #; 123 _ 16 CUSTOMER NO. 21#2 22 MDFROOKUM <br />1. Generator's Name, Address and Telephone Number <br />ATTR: <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />SToc;KTON, CA 95204- 61.1.7 <br />CUSTOMER NllMeEq 6 <br />2A. DESCRIPTION OF WASTE <br />UN3291 Regulated Medical Waste, <br />6.2, PGI) <br />UN3291, Regulated Medical Waste, <br />tx UN32 <br />91 <br />® 6.2, <br />UN3291 <br />X 6.2, PGII <br />W UN3291, <br />Z 6.21 PGII <br />W UN3291 <br />a a1) Drll <br />(209) 451-9031 <br />111852-001 GENERA•roR'sFlEGfSTRATION# <br />2B. CONTAINERTYPE <br />n.o.s., TB05 - 40 Gal Tub (Bio) (5.3 cu ft) <br />n.o.s., TH49 - 37 Gal Tub (Bis) (4.9 Cu ft) <br />TB14 - 44 Cal Tub(Bio) (5.9 11 tt) <br />n.o.s,,TB2i-(BTo)/TP15-(Path)/TY15-(Chemo)20 Gal Tub(2. <br />Waste, n.o.s., <br />Regulated Medical Waste, n.o.s., <br />Regulated Medical Waste, no.s., <br />Regulated Medical Waste, n.o.s, <br />W]331- (Bio) /WP31- (Pat:d1) /WC31- (Gheink',) 31 Gal TUD (4.14 <br />wnd3-(Sia)/z?w43-(Path)/CW43-(Chemo) Gal Tub(5.7CUFT) <br />tum - Biosystems Cardboard Bax (4_2 cu fit) <br />3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and a <br />des ed abovs by the props shipping name, and are cis Ified, packaged, marked and labelle ftl <br />$ In a( spects In proper c) dation for transpol accorddd to applicable international and national <br />Q. TR PORTER 1 ADD <br />w St uJaWle, Xn ® This is a <br />CC <br />4235 W. Swift Ave <br />°o Fresno,CA 93722 <br />a. a TRANSPORTER C,I*RTIFICATION: Receipt of medical waste as de a ?- <br />TOTALS 111, - <br />regulations." regulations° <br />1/9/2018 <br />2C. NO, OF 12D. VOLUME <br />CONTAINERS <br />�� Date -. ` r�" <br />Phone #. (866)783-7 22 <br />Applicable Permit Numbers: <br />Hauler Rteg# 3400 <br />Date l t ' <br />5. INTERMEDIATE= }CANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />Applicable Permit Numbers: <br />O o <br />05 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />M 5. INTERMEDIATI= HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone #: <br />Applicable Permit Numbers: <br />a � °zl INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />IPrint/iWe Name Slanature Date <br />5 <br />ti <br />Iz <br />ILu <br />I� <br />7. DISCREPANCY INDICATION <br />jf{8�4. Dosignatod Facility: L] 88. Alternate Factiity: U 8C. Alternate Facility: U so, Alternate Facinty: <br />SterIcycle, Inc, Sterlcycle, Inc. Sterlcycle, Inc. <br />4135 W. SwiftAvO 90 N. Foxboro Dave 1551 Shelton Drive <br />Freano,CAAyx>= OLS North Salt Lake, UT 84054 HoIllster, CA 55023 <br />(866)783-7422 (866)783-7422 <br />TSIOST22 3A-44NA-35 MOST l3a <br />JAN 0 9 2018 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indEgu"2!s in accordance with the requirement outlined in that authorization. <br />PrTnV?Ypo Name CC77 Signature Date <br />Transs{brrad c ntafners, au it to <br />US'tttallVAG <br />