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-- a--- — — --- - -- - - — MEDICAL WASTE TRACKING FORM NUMBER 00 ®, erlc cle' ASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424 STANDARD MANIFEST 001-10.06STO • Pratee4inghople.RedudngRljk- Route lir+: 123 — 16 CUSTOMER NO. 211 2 MDFROOK79Z 11.1 VI BA. Designated Facility: U 80. Alternate Facillty: I__i 8C. Altemate Facility: U 8D. Altomato Facility: tedcycle, Inc. Sbricycle, inc. Stertcyate, inc. 035 W. SWR AVG 9a N. Foxbora Drive 1551 Shelton Drive FresnD Nartb SeliLakke, UT 84054 HOJAstar, CA 95023 (8136)73- ._ NE OFtTIZ (868)703-7422 (866)793-7422 TS/OST22 TS/OST 83 FEB 0 6 2018 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have received the above l'W"�tes in accordance with the requirement outlined In that authorization. Print/Type Name Signature Data ORIGINAL 1. Generator's Name, Address and Telephone Number ATTN: GILL MEDICAL MNTER 1617 N CALIFORNIA ST S2'0CXTONr CA 9520Q— 61.17 (209) 451-9031 2/6/2018 CUSTOMER NUMBER 6111852-001 5GENERATOR'S REGISTRATION # 2A. DESCRIPTION OF WASTE 213. CONTAINERTYPE 2C. NO. OF 2D. VOLUME UN3291 Regulated Medical Waste, n o.s.,CONTAINERS 'IH05 - AO tial Ttzb {Hiu} {S.3 on ft) 6.2, PGI Cu Ft. UN3291. Regulated Medical Waste, n.o.s., 744- 37 Gal Tub (Dio) (4.9 cu ft) 6.2, PGI' Cu Ft. Regulated Medical Waste, n.o.s., H14 44 Gal Tub (Sio) (5.9 cu ;"t) QUN3291, 6.2, PGI! Cu Ft UN3291 Regulated Medical Waste, n.o.s., THIN- (g�0} TP1S- {Path} TYIS- (Chemo) 20 tial Tub {2.70irFT) 6.2, PGII Gu Ft. W UN3291 Regulated Medical Waste, n.o.s., WB31- (Bio)/WP31- (Fath)/WC31- (Chemo)31 Gal Tub (4.14Ci1F ) Z 6.2, PH Cu Ft. UN329PG 1 Regulated Regulated Medleal waste, mos.,wB43- (Bio) /t?i d2- (Path) /C�T43- (Chemo) tial Tub (5.7CUFT) Cu Ft. UN3291 Regulated Medical Waste, n.o.s, 6.2, PGI E= - Biosystems ,Cardboard Sox (4.2 cu ft) Cu Ft. UN3291Aagufated Medical Waste, n.o.s., 6.2, PGH Cu Ft UN3291 Regulated Medical Waste, n.o.s., Cu Ft 3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TALS �' r Cu Ft. El q described above by the proper shipping name, and are classified, packaged, marked and labeiled/placarded, a spects in proper ondition for transport according to applicable I ernational and natio ern nt gulatlons" # Ca V i.��`C� �� mc d/iyped Name L Sig ature Date TR PORTER 1 ADDRESS: Steri cls Inc. This is rough shipment cY Phone #: (06)-71133-7422 �- ccRe r 41.35 W. Swift Aveit Appilcable Permit Numbers: ]daulet: 3# 3400 a ur Fretyno,C7� 93722 per„ Z TRANSPORT RTIFICATiQN: Receipt of medical waste as describ d above j Print%pe Name Signature Date—(14iK: j 5. INTERMEDIA 2 / RA RT 2 DDRESS: Phone #, j ` Appltcable Permit Numbers. u90 Rg INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. j Printfiyps Name _ Signature Date j M 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #: a a Applicable Permit Numbers: f m Uja INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above PrinVIype Name Signature Date 7. DISCREPANCY INDICATION 11.1 VI BA. Designated Facility: U 80. Alternate Facillty: I__i 8C. Altemate Facility: U 8D. Altomato Facility: tedcycle, Inc. Sbricycle, inc. Stertcyate, inc. 035 W. SWR AVG 9a N. Foxbora Drive 1551 Shelton Drive FresnD Nartb SeliLakke, UT 84054 HOJAstar, CA 95023 (8136)73- ._ NE OFtTIZ (868)703-7422 (866)793-7422 TS/OST22 TS/OST 83 FEB 0 6 2018 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that i have received the above l'W"�tes in accordance with the requirement outlined In that authorization. Print/Type Name Signature Data ORIGINAL