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«'®• Ste c e' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.4249300
<br />••• n•uni�arssdr ua: Route #: 023 — 17 CUSTOMER NO. 21132 MDFROOGV3C
<br />1. Generator's Name, Address and Telephone Number
<br />AWN:
<br />GILL MEDICAL CENTER
<br />1617 N CALUCRAIIA ST
<br />mcnov, CA 95204- 6117
<br />12
<br />Designated Facility:
<br />SEP 01201 f
<br />r FACILITY I certify that I have
<br />above Indicate,wastes QjaCco
<br />ycle. Inc.
<br />Foxboro Wive
<br />Suit Linke, UT 84054
<br />Stericycle, Inc.
<br />1561 Shelbon Drive
<br />Hollister, CA 96023
<br />(ee9)783-7422
<br />TWOST 83
<br />Sbericycte, Inc.
<br />3140 N 7th Streetbry
<br />Kansas City, KS 6611 S
<br />(668)783.7422
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />s with the requirement outlined In that authorization.
<br />Signature
<br />(209) 451-9031
<br />9/1/2015
<br />CusTouERNUMBER 6111852-001, GENERATOR'S REGI M'nON#
<br />2A. DESCRIPTION OF WASTE 2B, i CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291, ReWWW Medical Waste. n o a,
<br />62. PGII TBO5 -+ 40 Gal Tub (Bio) (5.3 cu ft)
<br />Cu Ft,
<br />62 PGII Wash.noma, T849 - 37 Gal Tub (Bio) 0.9 tau ft)
<br />Cu FL
<br />p62,
<br />atad i Waste, TB14 -1X44 Gal Tub (Bio) (5.9 Cu ft)
<br />`
<br />II
<br />Cu FL
<br />UN3291, Regdatad Mesal Waal, n oz, TB21— (BIO) /TP35— (Path) /TY15— (Chemo) 20 tial Tub (2.7CUF
<br />6 2. PGII
<br />Cu Ft
<br />U1
<br />t, mated Madkbai waw, n o &, WB31—� Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUP )
<br />W
<br />PGII.
<br />6 8..22, , P
<br />Cu Ft
<br />8.2, PGII Ra>Icitated Medical waste, n.as„ W843- Bio) /.EV62- (Path) /=43- (Chemo) tial Tub (5.7CWT)
<br />Cu Ft
<br />6a3PPG6 Ragwated Marital Waste, nos, KRB '- Biosystems Cardboard Box (4.2 Cu ft)
<br />Cu Ft
<br />UNMI, Regulated Media Waste, n as.,
<br />8.$ PGII
<br />Cu Ft
<br />UN32111, Regulated MedlW Waste, nos.
<br />8.2, PGII
<br />Cu Ft
<br />3. Generator's Certification: "1 hereby declare that the contents of this consignment are f * and aaxrrra y TOTA
<br />Cu Ft
<br />above by the proper shipping name, and are dassilied, packaged, marked and Iabelled/placarded and
<br />a i r spects In proper condition for transport a�rding to applicable mtemational and nattona nt !I regu ns
<br />50
<br />'or
<br />Prtn ed Narne0/0
<br />LA 81 nature
<br />U le
<br />PORTER I ADDRESS: ,
<br />Phone # '(86i)-71113-7422
<br />Stericycle, Inc. This is a Through shipment
<br />ApplicablePermilNumbers
<br />4135 A. Swift Ave
<br />Hauler Reg# 3400
<br />®
<br />Fresno,CA 93722
<br />E2W
<br />TRANSPORTER CERTIFIC: Recalpt of medical waste as des d a
<br />PrinVryps Name 154—Signature
<br />Date
<br />N
<br />5. INTERMEDIATE HANDLEK 21 NSPORTER 2 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printtrype Name Signature
<br />Date
<br />n
<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone P.
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER. CERTIFICATION: Receipt of medical' waste as described above.
<br />Printltype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />Transferred cafflalners, ou ft to : Nolth Sat Lake, UT
<br />12
<br />Designated Facility:
<br />SEP 01201 f
<br />r FACILITY I certify that I have
<br />above Indicate,wastes QjaCco
<br />ycle. Inc.
<br />Foxboro Wive
<br />Suit Linke, UT 84054
<br />Stericycle, Inc.
<br />1561 Shelbon Drive
<br />Hollister, CA 96023
<br />(ee9)783-7422
<br />TWOST 83
<br />Sbericycte, Inc.
<br />3140 N 7th Streetbry
<br />Kansas City, KS 6611 S
<br />(668)783.7422
<br />authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />s with the requirement outlined In that authorization.
<br />Signature
<br />
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