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('-- MEDICAL WASTE TRACKING FORM NUMBER <br />®®� 5teC'gde' ASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424 STANDARD MANIFEST 001 -10 -06 -STD <br />®° praindinghopEeRed.dngfRisk, Route #; 123 — 21 CUSTOMER NO. 21132 MDFROOK.SBV <br />' <br />'t. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N ChLTFORNIA ST <br />STOCrMN, CA 95204- 6117 <br />f <br />(209) 451-9031 <br />1/30/2018 <br />i <br />CUSTOMER NUMBER 611"1852-001 GENERATOR'S REGISTRATIDN # <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINERTYPE <br />20. NO. OF <br />20. VOLUME <br />UN3291 Regulated Medical Waste, n.o s., <br />6.2, PGII <br />TB05 — 40 Gal Tub (Bios• (5.3 CU ft) <br />CONTAINERS <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />TH49 — 37 Gal Tub (Rio) (4, 9 cu ft) <br />Cu Ft. <br />l p <br />UN3291 Regulated Medical Waste, 0.0's"TB14 <br />44 Gal Tub (Sip) (5.9 cu -Et) <br />c Cu Ft. <br />Q <br />UN3291 Regulated Medical Waste, n.o.s., <br />T821— ($iO) /TP1S— (Path) /TY1S— (Chemo) 20 Gal Tub (2.7CUFT) <br />M <br />6.2, Poll <br />Cu Ft. <br />W <br />UN3291,Regulated Medical Waste, n.o.s.,Wg31— <br />(Bio) /WP3.t - (Pat h) /WC31— (Che ino) 31 Gal Tub (4.14CETF <br />) <br />6,2, PGII <br />Cu Ft. <br />tZ <br />RegulatedMedical Waste, n.o.s., <br />623 1432911 Regulated <br />WB43—(LUo)/PW43—(Path)/CW43—(Chemo) tial Tub(5.7CUFT) <br />Cu Ft. <br />6123291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />M — Biosystems cardboard Bax (4.2 cu ft) <br />� <br />Cu Ft <br />UN3291 Regulated Medical Waste, n.o.s., <br />_ <br />6.2, P61I <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately [TOTALS 0- <br />des21AW above by the proper shipping name, and are classified, packaged, marked and labelled! rd, and <br />re Ia spects In proper condition for transport according to International and net gov mental ulations" <br />ja�pplicable <br />iff �� <br />r _ F fedllypedNamasil''^�I Sfgnat" ure <br />a/N to <br />SPORTER 1 ADDRESS: <br />Steticycle, Inc. ® This is a Throu hipment <br />Phone #: (86 -6r -n3-7422 <br />Applicable Permit Numbers - <br />KC <br />4135 W. swift Ave <br />i7$Lt1eD Reg# 3900 <br />KC o° <br />m <br />Freistto, CA 93722 <br />a a <br />TRANSPORT TIFI A Receipt/off medic I waste as described a eve. <br />Print/"fype Name / Signature <br />Date <br />S. INTERMEDIATE LE 7 ANS ORTER 2 ADDRESS: <br />Phone #: <br />hApplicable <br />Permit Numbers: <br />N� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Prinnpe Name Signature <br />Date <br />M <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS- <br />Phone #. <br />: :152 <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />j <br />— <br />PrinMpe Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />?- <br />A. Dealgnatod Facility: 8e. Alternate Facility: [] 8C.Altemate Facility: <br />❑ 8D. Alternate Facility: <br />s le, Inc. Stericycle, Inc. Stericycle, inc. <br />cs <br />4135 W. SwtftAve 90 N. Foxtioro Drtva 1851 Shelton Drive <br />Fresno,CA 93722 North Salt Lake, UT 84054 Hollister, CA 85023 <br />►- <br />(866)783 (966)x"83-7422 (866)783-7422 <br />j�ANNEOf3TIZ <br />TSiOST M -40 -JA -36 TWOST 83 <br />TREATMENT MAP that I have been by the to i have <br />qwq� <br />t— <br />cNIP authorized applicable state agency accept untreated medical <br />received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br />wastes and that <br />` <br />Print%pe Name Signature <br />Date <br />Transferred containers, cu R to <br />Ail <br />d� <br />ORIGINAL <br />