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<br />®p® Protealpi;hople.Awalpgft1 :
<br />ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-42
<br />tate #: 123 — 21 CUSTOMER NO.2 2
<br />MEDICAL WASTE TRACKING FORM NUMBER
<br />STANDARD MANIFEST 001 -10.09 -STD
<br />MDFROOM FS
<br />L" gREATMENT FACILY• CB y that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above t Ptes in accordance with the requirement outlined in that authorization.
<br />E.-.
<br />Printfiype Name Signature
<br />Transferred containers, cu R to :
<br />ORIGINAL
<br />Date
<br />i. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 V CALIFORNIA ST
<br />STOCIiMN, CA 95204— 6117
<br />(209) 451-9031 1/16/2018
<br />CUSTOMER NUMBER 6111852-001 GENERATOR,s REGISTRATION#
<br />2A. DESCRIPTION OFWASTE
<br />2e. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TBO5 — 40 Gal. Tub (Bio) (5,3 cu ft)
<br />CONTAINERS
<br />Cu Ft
<br />62329PGII Regulated Medical Waste, n.o.s.,
<br />T— 37 Gal Tub (Bio) (11.9 Cil 'Et)
<br />Cu Ft.
<br />®
<br />623P2GII Regulated Medical Waste, n,o.s.,
<br />B14 — 44 Gal TUT (010) (5, 9 Cil ,fit)
<br />Cu Ft.
<br />Q
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />TB21— (BIO) /TP15— (Path) /TY1S-- f Chemo) 20 tial Tub (2.7CETFT
<br />IM
<br />6.2, PGII
<br />Cu Ft.
<br />tit
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6,2, PGII
<br />WB31— (Bio) /WP31— (Pat h) /WC31— (Chemo) 31 Gal Tub (4.14Cf7F
<br />)
<br />cu Ft.
<br />fZ
<br />6 2, pGIj Regulated Medical Waste, n,o.s.,
<br />W963— (Bio)/EW43— (Path) /CW43— (Chemo) Ga3. Tub (5.7CUFT)
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, nz s,,
<br />8.2, PGII,
<br />ARB — Biosystems Cardboard Box (4.2 au ft)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, mo.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS %^ r Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelle rded, and
<br />,aTTIna spacts in proper condition for transport according to appitcab a fnternatI nal and n v ment egufatfons°
<br />1 V
<br />1 PrI ed/typed Name nature Date P 't
<br />R PORTER 1 ADDRESS: Phone #: (866) 783-7422
<br />SteriGyCle, Inc. ® This is a Through shipment Applicable Permit Numbers:
<br />0
<br />4135 W. Swift: Ave Hauler Reg# 3400
<br />� a'
<br />Feesino,CA 93722
<br />.a Z
<br />TRANSPORTS RTf IC : Recelp medical waste as described a va.
<br />Prinnpe Name Signature Date Q�
<br />5. INTERMEDIATE HANDLE 2 /TRANSPORTER 2 ADDRESS: Phone #:
<br />IH§
<br />Applicable Permit Numbers:
<br />on.�o
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />6. INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone #:
<br />E9Applicable
<br />Permit Numbers:
<br />°
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />s
<br />Printttyype Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />d Facility:
<br />Ej Be. Altomato Facility:
<br />❑ SC.Altemate Facility:
<br />So. Alternate Facility:
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />Drive
<br />4186 W. SW ftAva
<br />NE OR IZ
<br />SO N. Foxboro Drhro
<br />1661 Shelton
<br />Fresno,
<br />North Salt Lake, UT 84054
<br />Hollister, CA 95023
<br />(81)783-7422
<br />T1,011,
<br />(866)783.7422
<br />$A
<br />(866)783-7422
<br />TS/OST 83
<br />JAN 16 2018
<br />-446%W36
<br />L" gREATMENT FACILY• CB y that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above t Ptes in accordance with the requirement outlined in that authorization.
<br />E.-.
<br />Printfiype Name Signature
<br />Transferred containers, cu R to :
<br />ORIGINAL
<br />Date
<br />
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