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MEDICAL WASTE TRACKING FORM NUMBER -
<br />O® Ster'C'ycle* IN CASE OF EMERGENCY CONTACT: CHEMTREC•1-800424-93 STANDARD MANIFEST 001.10-D•STD
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<br />• pmudragP"PI•Redv&ipRhk Rothe #: 123 - 22 CUSTOMER NO. 21132
<br />MDFROOKA5C
<br />1. Generator's Name, Address and Telephone Number
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<br />GILL 14EnICAL Ci:.NM
<br />1.617 W CALIFORNIA ST
<br />STCCXTOIIr CA 95204— 6117
<br />(209) 451-9031
<br />2/27/201B
<br />CusTOMER NUMBER 6111852-001 GENERArows REGISTRATION#
<br />2A. DESCRIPTION OFWASTE
<br />28. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />TB05 - 40 Gal 'Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
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<br />UN3291 Regulated Medical Waste, 111018.1
<br />TH49 - 37 Gal Tub (Bi,p) (4.9 CU ft)
<br />6.2, Poll
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<br />UN3291 Regulated Medical Waste, 11.0.8.,19
<br />44 rail Tub, (Bina) (S. 9 cu ft)
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<br />fi,2, PGII
<br />Gu Ft
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<br />UN3291 Regulated Medical Waste, n.0.s.,
<br />6.2, PGI j
<br />TB21- (BXO) TP15- (Path)T'Y15- (Cheino) 20 Gal Tub (2.7Gu1+Tj
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<br />Cu Ft.
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<br />2
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGI1
<br />WB31- (Biu) /WP3.1- (Path) IWC31- (Chemo) 31 Gal Tub (4.14CUF
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<br />Cu Ft
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<br />UN, 291 Regulated Medical Waste, mms.,
<br />6.2, PGI1
<br />WBd3_ (Eio) /$W¢3_ (gatb) ICW43- (Gh moo) Gal Tuts (5.7CtJFT)
<br />Cu Ft.
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<br />UN3291 Regulated Medical Waste, n,o.s.,
<br />6.2, PGII
<br />KRB - Biosystems Cardboard Box (4-2 cu ft)
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<br />Cu Ft.
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<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />I6,2,
<br />PGII
<br />Cu Ft '
<br />UN3291, Regulated Medical Waste, n.o.s„
<br />6.2, PGII
<br />Cu Ft.
<br />3. Generator's Certificgtlon' "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®
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<br />dasrdbed above by the proper shipping name, and are classified, packaged, marked and label d, and
<br />e in a aspects In proper condition for transport according to applicable international and na n 1 gbVkrnmentaf regulations"
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<br />4. TRANSPORTER 1 ADgRE�S
<br />St@c�cyalt�, Ino. This is rough Shipment
<br />Phone #: d "
<br />49,35 1111. Ave
<br />Applicable Permit Numbers:
<br />_Swift
<br />Baulec Reg(#,3400
<br />:910
<br />Fresno,CA 93722
<br />W0�„
<br />TRANSPORT CE IFICATiON: Receipt of medical waste as dead edd
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<br />Prinmpo Na2
<br />a Signator
<br />Date
<br />S. INTERMEDIATE HAN16EER 2/TRANSPORTER 2 ADDRESS-
<br />Phone #:
<br />N
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt ofimedlcal waste as described above
<br />Print/Type Name Signature +
<br />Date
<br />MW
<br />8. INTERMEDIATE JlANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />+
<br />Applicable Permit Numbers.
<br />N
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION_: Receipt of,medicat waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />7.015 PANCY INDICATION
<br />7
<br />6A. Designated Facility: 9B. Alternate Facility: ❑ 8C. Altemata Facility: E] so. Aitamate Facility:
<br />i, Is. Inc. Stericycla, Inc. Stericycle, Inc.
<br />' W,
<br />Covanta Marlon,lnc
<br />4135
<br />� 90 N. Foxboro Dave 1551 Shelton Dove -
<br />NE OFMZ
<br />4850 Brooklake Road NE
<br />a
<br />.' Frgsno, - North Salt Lake, UT 84054 Hollister, CA. 95023
<br />Brooks, OR 97305
<br />.'j$66)783-7422 (801)936- I t 71 (866)783-7422
<br />(505)393-08910
<br />W91:$
<br />77; T_'2 27 3A.- 48MA-36 TSIOST-83
<br />Perrt'tEt# 364
<br />201
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<br />®rTREATME
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<br />FACILA944didy that I have been authorized by the applicable state agency to accept untreated medical
<br />wastes and that I have
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<br />received the above indicatedW5slas in accordance with the requirement outlined In that authorization.
<br />Print%pe Name Signature
<br />Date
<br />Transferred containers, CU R to
<br />161-:116-11 fT1A
<br />
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