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®®!®® Step IcVc�Q® IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.4249300
<br />sretee.yH w`���` Routs #: 023 _ 5 CUSTOMER NO. 21132
<br />Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />4617 N CALTFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />ff 852-003 GENERATOR'eREOIa mmoN#
<br />29. CONTAINER TYPE
<br />' xtL2 — 4u URL 'l'— (tl 7 (J 3 Cil myi l
<br />T849 - 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TB14 - 44 _Gal Tub(Bio) (5.9 Cu ft)
<br />TS21—(BXO)/TPi5—(Path)/2X15—(Chemo)20 Gal Tub(2.
<br />W931—(Biot/WP31—(Path)/WC31—(Chemo)31 Gal Tub(4.
<br />Certification: "I hereby declare that the contents of this consignment are 11
<br />3 by the proper shipping name, and are classified, packaged, marked and IF
<br />ft in Proper oaldiddi for transport according to�appt&zbie InternaNc M and
<br />CONTAINERS
<br />0
<br />Cu Ft
<br />Cu Ft.
<br />Cu Ft.
<br />Cu Ft
<br />Cu Ft.
<br />Cu FL
<br />CU Ft.
<br />Cu Ft
<br />4. TRANPORTERIADDRESS:Phone# (866_)753-7422
<br />a Stericycle, Inc . This a ugh ehipment Applicable Permit umbers:
<br />4135 N. Swift Ave Hauler Reg# 3400
<br />Fresno,CA 937J _
<br />z TRANSPORT RTiFICATiHp4 of mom! stn as descnb a Li
<br />PrInIfTyps Narita SlgneWre Date—~� I
<br />N 5. INTERMEDIATE HANDLER 27 TRANSPORTER 2 ADDRESS: t. r , /�Phone #
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature Data
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone*
<br />Applicable Permit Numbers:
<br />3 INTERMEDIATE HANDLER J TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z 3
<br />— Pdntfflme Name - Sionature Date
<br />to
<br />Transferred containers, cu h to : North Sak Lake, UT
<br />u- 4136 . svuflt Acre AUTOCAVE 90 N. Fi
<br />Frown ,CAS 7 LE ANNE'ORt tib s
<br />(866)7 &7422 6)78
<br />T9/0 AUG 18 2015 8-
<br />I TREATMENT ACILI1'Y, I certify that I have been ei
<br />received thea ova indtcated wastes In a r
<br />lPdnVrypo Name.
<br />Cr?
<br />Q
<br />Inc.
<br />CUSTOMER NUMBER 61
<br />2A. DESCRIPTION OF WASTE
<br />Stericycle, Inc.
<br />oro ®rte
<br />UN3291, Regulataci Medirel Waste, nae.,
<br />8 2. PGII
<br />.ala, LIT 840FA
<br />U0291, Regulated Madcal Waste, nam..
<br />6.21, PGII
<br />UN3291. Regcdeted Morel Waste, no e.,
<br />a/
<br />O
<br />8$ Poll
<br />UN3291, Regulated MerAcal Waate, nu.:
<br />TSIOST 83
<br />8.2. PGII
<br />UN3291, RoguWW Mer9cal Waste, rms ,
<br />W
<br />W
<br />8.2. PGII
<br />UN3291, Re(((nted Medial Waste, n o a,
<br />8.2, PGII
<br />UN3291, Regcda W Medial Waste, n o s„
<br />Date
<br />8.2. PGII
<br />UN3291, Regulslat Medd Waste, n o s.,
<br />8.2. PGII
<br />UN3291, Regulnlnd Medksl Warta, no e.,
<br />ff 852-003 GENERATOR'eREOIa mmoN#
<br />29. CONTAINER TYPE
<br />' xtL2 — 4u URL 'l'— (tl 7 (J 3 Cil myi l
<br />T849 - 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TB14 - 44 _Gal Tub(Bio) (5.9 Cu ft)
<br />TS21—(BXO)/TPi5—(Path)/2X15—(Chemo)20 Gal Tub(2.
<br />W931—(Biot/WP31—(Path)/WC31—(Chemo)31 Gal Tub(4.
<br />Certification: "I hereby declare that the contents of this consignment are 11
<br />3 by the proper shipping name, and are classified, packaged, marked and IF
<br />ft in Proper oaldiddi for transport according to�appt&zbie InternaNc M and
<br />CONTAINERS
<br />0
<br />Cu Ft
<br />Cu Ft.
<br />Cu Ft.
<br />Cu Ft
<br />Cu Ft.
<br />Cu FL
<br />CU Ft.
<br />Cu Ft
<br />4. TRANPORTERIADDRESS:Phone# (866_)753-7422
<br />a Stericycle, Inc . This a ugh ehipment Applicable Permit umbers:
<br />4135 N. Swift Ave Hauler Reg# 3400
<br />Fresno,CA 937J _
<br />z TRANSPORT RTiFICATiHp4 of mom! stn as descnb a Li
<br />PrInIfTyps Narita SlgneWre Date—~� I
<br />N 5. INTERMEDIATE HANDLER 27 TRANSPORTER 2 ADDRESS: t. r , /�Phone #
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinUType Name Signature Data
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone*
<br />Applicable Permit Numbers:
<br />3 INTERMEDIATE HANDLER J TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z 3
<br />— Pdntfflme Name - Sionature Date
<br />to
<br />Transferred containers, cu h to : North Sak Lake, UT
<br />u- 4136 . svuflt Acre AUTOCAVE 90 N. Fi
<br />Frown ,CAS 7 LE ANNE'ORt tib s
<br />(866)7 &7422 6)78
<br />T9/0 AUG 18 2015 8-
<br />I TREATMENT ACILI1'Y, I certify that I have been ei
<br />received thea ova indtcated wastes In a r
<br />lPdnVrypo Name.
<br />Cr?
<br />Q
<br />Inc.
<br />Stericycle, Inc.
<br />Stericycle, Inc.
<br />oro ®rte
<br />1551 Shobn oft"
<br />3140 N 7th Streetttty
<br />.ala, LIT 840FA
<br />Hollister, CA 96023
<br />Kanaaa City, KS 66115
<br />422
<br />(866)783-7422
<br />(866)783-7422
<br />36
<br />TSIOST 83
<br />TMST -26
<br />)rized by the applicable
<br />state agency to accept untreated medical wastes and that I have
<br />the requirement outlined in that authorization.
<br />iignalura
<br />Date
<br />
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