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• MEDICAL WASTE TRACKING FORM NUMBER
<br />•` ®® Sierwcycle• ASE OF EMERGENCY CONTACT: CHEMTREC 1.800.42 STANDARD MANIFEST 0011-10-06STD
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<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
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<br />11111111 �11111
<br />GILL MEDICAL CENTER
<br />1617 N CALIir'ORNTA ST
<br />STOCKTON, GA 95204- 6117
<br />(209' 451-9031
<br />2/13/2018
<br />CUSTOMER NUMBER � � � � � GENERATOR'S REeISTRATIONO
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />T805 — 40 Gal Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />Cu Ft
<br />UNS291 Regulated Medical waste, n,o.s.,T
<br />9 - 37 Gal Tub (Bio) (4.9 cu tt)
<br />6.2, PGI
<br />Cu Ft,
<br />I=
<br />UN3291 Regulated Medical Waste, Mies"
<br />Bl4 - 44 Gal Tub (Bio) (5.9 cu tt)
<br />6,2, PGII
<br />Cu Ft,
<br />Q
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />— o P — Ba TY — C emo eal T CUFT
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<br />6.2, PGII
<br />Cu Ft,
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />WB31- (Bio) 7WP3.k- {Paris} /Wc31- (Chemo)31 Gal Tub (4.14CUF
<br />)
<br />6.2, Pail
<br />Cu Ft
<br />ttZ
<br />Regulated Medical Waste, n.o.s.,
<br />talfi63- (Hia} /PWtl9- (Path) /C47d3- (Chemo) tial Tub (5.7CUPT)
<br />6N3291
<br />Cu Ft.
<br />UN3291 ,Regulated Medical Waste, n.o,s.,
<br />KRD - Biosystems Cardboard Box (4.2 cu ft)
<br />6.2, PGII,
<br />---
<br />Cu FL
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu R.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.21 Poll
<br />Cu Ft
<br />3. Gen is certification: 11 hereby declare that the contents of this conslgnment,are fully and accurately TOTALS 110-
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<br />a ove by the proper shipping name, and are classified, packaged, marked and labelled/pia ed, a
<br />ra In all r acts In prop4r condition for transport according to appilcabl� international and natio g me t regulations:'
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<br />,Printe yped Name * °� ig ture
<br />Date
<br />4. TRA RTER i ffHE S:
<br />Stet: Cycle, IRG. ® This is 8 ough shipment
<br />Phone t
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<br />4135 V. Swift: Ave
<br />Applicable Permit Numbers:
<br />Hauler Reg# 3400
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<br />Ft eBna, GA 937$2
<br />a ZTRANSPORT
<br />PERTIFIC TI etpt of medical waste as describ&,,,
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<br />Printlrype Name Signature
<br />Date
<br />5. INTERMEDIATE H LER ! ANSPORTER 2 ADDRESS: t.71
<br />Phone 4:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANbLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrintCType Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3/ TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
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<br />Print[Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />LJOA. Doeignated Facility: ❑ Be. Alternato Facility: ® 8C. Alternate Facility: ® 8D. Aitornate Facility:
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<br />a. Inc. Sfisricycle, Inc. Stericycle. Inc.
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<br />4135 W. SWRAve 90 N. F040110 D11ve 1551 Shelton orw
<br />Frasn 8 E ORTIZ North Salt Lake. LIT 84054 HaRlster, CA 95023
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<br />(SM783-7422 (866)783+7422
<br />TS/OST22 8A.448-JAr86 TSff3ST 83
<br />FEB 1 7n16
<br />TREATMENT FACT11,�QT�Y fy that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the abovedt; stes in accordance with the requirement outlined in that authorization.
<br />Print/typa Name Signature
<br />Date
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<br />ORIGINAL
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