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—�r — MEDICAL WASTE TRACKING FORM NUMBER
<br />`• p w STANDARD MANIFEST 001 -10.06 -STD
<br />Sl�et'iC�/�1@ ASE OF EMERGENCY CONTACT: CHEMTREC 1 -BOD -424-
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<br />Protecting Pwple.Rsd.angppk Route #: 123 — 5 CUSTOMER NO. 21132 MDFROQI{96Z
<br />ORIGINAL
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CAI,iroRNIA ST
<br />ST'OGI€'IN, CA 35204— 6117
<br />(209) 451--9031
<br />2/20!2418
<br />CusmmERNumsm 6111852-001 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OFWASTE
<br />28. CONTAINERTYPE
<br />20. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TBOS --40 coal Tuts (Rio) (5-3 cu it)
<br />CONTAINERS
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />TB49 _ 37 Gal Tub (Bio) (4.9 cu ft)
<br />Cu Ft.
<br />cc
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
<br />TBl _ q Gal Tub(Bio) {5.9 cu ft)
<br />Cu Ft
<br />UN3291Regulated Medical Waste, U.S.,
<br />T1321— (BTO) /Tp15— (Pat_h) /TY15— (Chemo) 20 {dal Tub (2.7CUFT)
<br />6.2, PGiI
<br />Cu Ft.
<br />Z
<br />UN329i, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />WB31— (Bio) /WP31— (Path) /WC31— (Ch�etno) 31 Gal Tub (4.19CUFT
<br />Cu R.
<br />Uj
<br />UN3291 Regulated Medical Waste, n.e,s.,
<br />6.2, PGII
<br />wB43— (Bio) /t?wd3- (Path) /Ctii93— (Chemo) Gal Tub {5.7CUF`T)
<br />Cu Ft.
<br />UN329i Regulated Medical Waste, n.o.s.,
<br />fi.2, PGII
<br />KRR — Bi-osysteMS cardboard Box (4.2 cu £t)
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291 Regulated Medical Waste, u.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 T®TQL.S i
<br />.i ., Cu Ft
<br />d e ova by the proper shipping name, and are classified, packaged, marked and labelled/pi rded, and
<br />re In all r acts in proper condition for transport omental regulations°
<br />to applicable International and nEak
<br />�acccord�itnrg
<br />t � � V E U� L �� Ua
<br />Da �40 I ��
<br />Printe ypad Nama t ^�t1 A
<br />4. TRANS RTER I ADDRESS:
<br />Ste•:cicya Inc. ® This i s a Through shipment
<br />Phone #: (966) 703-7422
<br />Applicable Permit Numbers:
<br />cc
<br />4135 W. swift Ave
<br />Hauler Reg# 3400
<br />m!'ream,
<br />CA 93722
<br />non
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<br />TRANSPORTS T F1CAT N: Receipt of medical waste as describe ove.
<br />,�1n1
<br />��l /. /4
<br />VVV
<br />Date
<br />Print(lype Name Signature
<br />6. INTERMEDIATE HANDL 2 /TRANSPORTS 2 ADDRESS:
<br />Phone #:
<br />fluApplicable
<br />Permit Numbers:
<br />NN
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printflype Name Signature
<br />Date
<br />t,
<br />S. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS.
<br />Phone #:
<br />aApplicable
<br />a
<br />Permd Numbers:
<br />* a
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />zs
<br />—
<br />Pr1nUPypeName Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Facility:
<br />E] Alternate Facility:
<br />SA. Designated Faculty: 88. Alternate Facility: ❑ 8C. Alternate
<br />SD.
<br />402
<br />terlcycle, Inc. Stericycle, Inc. Sterlcycle, Inc.
<br />4135 W. SWIftAV* 90 N. Foxboro Drive 1651 Shelton Drive
<br />Fresno,CA 93722 North Salt Lake, LIT 84055 Hollister, CA 85023
<br />(866)783-7422 (886)783-7422 (866)783-7422
<br />TS/OST22 3A -440-A-36 TS/OST 83
<br />51
<br />DALE M ( -NE ORTIZ
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />received the aabBeoveinndicatteDhwastes in accordance with the requirement outlined In that authorization.
<br />FET¢¢
<br />Prinl/lype Name Signature
<br />Date
<br />cwz
<br />&A Transferred containers, CU tt to
<br />ORIGINAL
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