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<br />MEDICAL. WASTE TRACKING FORM NUMBER
<br />ASE OF EMERGENCY CONTACT: CHEMTREC I-BODA24 STANDARD MANIFEST 001-10-06-STD
<br />re #S 123 — 4 CUSTOMER NO.21 MDFROOK5E4
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<br />1. Generator's Name, Address and Telephone Number
<br />ATTN: III 1111111111111111111111111111111111111111111111111111111
<br />GILL MEDICAL CENTER
<br />1.6:1.7 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(20.9) 451-9031
<br />1/23/2018
<br />CUSTOMER NUMBER 6111852-00-1 GENERATomsREGISTRATION #
<br />2A, DESCRIPTION OF WASTE
<br />213• CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medica! Waste, n.o.s.,
<br />6.2, PH
<br />TH05 — 40 Gal, Tub (Bio) (5.3 cu Et)
<br />CONTAINERS
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<br />UN3291, Regulated Medical Waste, n.a.s.,
<br />6.2, P(3311
<br />T849 - 37 Gal Tub (Bio) (4.9 cu ft)
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<br />N3229G11` Regulated Medical Waste, n.o s.,
<br />1g - 44 Gal Tub(Bio) (5.9 cu it)
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />TB21- (Blo) /TP15— (Path) /TY15— (Chemo) 20 Gal Tub (2.7CUFfi
<br />6.2, PGI1
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<br />UN3291 Regulated Medical Waste, n.o.s ,
<br />WB31— (bio) /WP31— (Fath) /li c31— (Chemo) 31 Gal Tub (4.14CUF
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<br />6.2, PGII
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<br />6 2, PPG11� Regulated Medical We ste, n.o.s.,
<br />WB43— (Bio) /PW43— (Path) /CW43— (Chemo) Gal. Tub (5.7CUFT)
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<br />6.2, Pa ,Regulated Medical Waste, n.o.s.,
<br />6.2, PGI
<br />KRB___, - Biosystems Cardboard Box (4.2 cu ft)
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291 , Regulated Medical Waste, n.os.,
<br />6.2, PGI{
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<br />3. Gonorator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
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<br />descr ove by the proper shipping name, and are classified, packaged, marked and labellir
<br />al acts In proper condition for transport according to applicab international an atI regulations"
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<br />4.TRANS ER 1 ADDRESS:
<br />Stericycle, Inc. ❑ This 5 - Shipment
<br />Phone #: 66 83-7422
<br />Applicable Permit Numbers:
<br />4135 W. Swift Ave
<br />Flauler Reg# 3400
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<br />Freano,CA 93722
<br />ME
<br />TRANSPORTS IFl TI ecelpf of cal waste as described a Va.
<br />23 :1 5
<br />PrintlType Name Signature
<br />Date
<br />S. INTERMEDIATE HAMLERWTFfANSPORTER 2 ADDRESS:
<br />Phone #:
<br />ffi
<br />Applicable Permit Numbers:
<br />Ra
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrInMpe Name Signature
<br />Date
<br />8. INTERMEDIATE HANDLSR 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />a
<br />Applicable Permit Numbers.
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<br />IN AT E1HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />BA. Designated Facility: L] BB. Altemate Facility: SC.Altemate Facility:
<br />[] 8D. Altemate Facility:
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<br />ericycle, Inc. Stericycle, inc. Stsdcycle, inc.
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<br />41 $5 W. SWIRAV* 80 N. FMOW4 D"o 1561 ShIlifton DI1ih6
<br />E+resna CA 9372 North Salt Lake, UT 84054 Hollister. CA 96023
<br />(866)7 3-7 &MEO
<br />(8615)783-7422 (866)783-7422
<br />W IfTSIOST22
<br />3A-4d8-,Wsa TSfOST 83
<br />JAN 2 9 2018
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that 1 have
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<br />received the above Ind glyVis in accordance with the requirement outlined in that authorization.
<br />PrinMpe Name Signature
<br />Date
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