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<br />!•e, S#erlIF c e° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />�191Ca"°Pao�-yy,.�`' Route #: 023 — 7 1 CUSTOMER NO. 21132 M12FROOG1141
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 11 CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />i
<br />CUSTOMER NUMBER 61318-1
<br />2A. DESCRIPTION OF WASTE 28.
<br />tk13291, Regulated Medi Waste, n o s ,
<br />6.$ PGII
<br />UN3291, Regulated Medi Waste, n.os.,
<br />6 $ PGII
<br />IX UN3291, Regulated Medical Waeto, nos.,
<br />® 6.2, PGR
<br />UN329I, Regulated Medical nos.,
<br />6.2, PGII
<br />Ill UN3291, Regulated Medical Waste, n o s-,
<br />W 62. PGII
<br />UN3291, Regulated Medical Waste, Rica..
<br />6.2, PGII
<br />UN3291, Regulated Mesal Waste, nos.,
<br />6
<br />451-9031
<br />GENERAToRz REOISTRAT[oN #
<br />CONTAINER TYPE 2C. NO. OF
<br />CONTAINERS
<br />TBOS - 40 Gal Tub (Bio) (5.3 Cu ft)
<br />TB49 - 37 Gal Tub (Bio) (4.9 Cu i:t)
<br />TB14 - 44 Gal Tub(Bio) (5.9 Cu ft)
<br />TB2.1•- (BIO) /TP15- (Path) /TYIS - (Chemo) 20 Gal Tub (2.7CM
<br />WB31-- (Bio) /WB31— (Path) /WC31— (Chemo) 31 Gal Tub(4.14CT
<br />WB43— (Bio) /Pt443— (Path) /CW43— (Chemo) Gal Tub (5.'tCUFT)
<br />KRB - Biosystems Cardboard Box (9.2 cu ft)
<br />UN3291, Regulated Mai Waste, nos,
<br />6 2, PGII
<br />UN3291, Medbai Waste, nA a ,
<br />62, PGII
<br />3. Generator's Certfffcatlon: 'I hereby declare that the contents of this consignment are fully, and acx rately TOTALS
<br />described above by the proper shipping name, and are classified, packaged, marked and iabeited/pia ed, an
<br />are In all respects In proper condition for transport according to applicable intemabonal and naborpl1ovel'amentil regulations'
<br />r
<br />PrIntedilyped Name . x A—P r r l nature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Stericycle, Inc. [� This is a rough shipment
<br />4135 E. Swift Ave F
<br />Fresno,CA 93722
<br />a TRANSPORT CE IPIM:YReceipt AeA� of medical waste as escdb a ve.PdnV ype Name_ SEgna
<br />5/2015
<br />Phone #:
<br />Applicable Permit Numbers:
<br />E,auler Reg# 3400
<br />Date
<br />Cu Ft
<br />Cu Ft.
<br />Cu Ft.
<br />Cu R.
<br />® Cu FL
<br />Cu Ft
<br />Cu Ft
<br />Cu Ft
<br />Cu Ft
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<br />ORIGINAL TRACKING DOCUMENT
<br />.,
<br />S. INTERMEDIATE HANDL 2 / SPORTER DRESS:
<br />Phone M
<br />NS
<br />ApplIcable Permit Numbers:
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnV ype Name Signature
<br />Date
<br />i
<br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS:
<br />Phone P
<br />S
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER I TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrinVfype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATI
<br />Transferred containers, -cu R to : North Sail Lake, LIT
<br />Designated of lln. ® 8B. Alternate Facility: p SC. Alternate Facility:
<br />80. Alternate Facility:
<br />Stertcycta, Inc. Sberlcycte. Inc.
<br />Sa�hRAve '�` 80 N, Foxboro 06" 1551 Shelton Drive
<br />Stsrtcycle. Inc.
<br />1
<br />9140 N 7th Streetttiy
<br />16,,
<br />a
<br />A 93 North Sail Lake, UT 84054 1-10111ster, CA 95023
<br />83-7 (866)783-7422 (866)783-7422
<br />Kansas City, KS 66115
<br />(866)783-7422
<br />lu
<br />(O
<br />® Tl 3Ar448-,1A 36 TSIOST 83
<br />TSI©ST-28
<br />TR N`T FA IL fy that I have been authorized by the applicable state agency to apt untreated medical wastes and that I have
<br />Cei ee4 abRv_I d wastes In accordance With the requirement outlined in that authonzation.
<br />Petit p1pe Signature
<br />Date
<br />� V
<br />ORIGINAL TRACKING DOCUMENT
<br />.,
<br />
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