|
F. f received
<br />Pdnt/lype
<br />I
<br />r PACT ��Yce thayWrida
<br />b®enuthorized bqy the applicable state agency to accept untreated medical wastes and that I have
<br />above i dY �tes5tnc with the requirement outlined In that authorization
<br />e Signature Date
<br />Ta1'CaAG DOCUMENT
<br />• ®! Ster'cycle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800.424-9300
<br />t • ro •ag1i4• ltflute #: 023 — 8 CUSTOMER NO. 21132 MDFR00GVZO
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />(209) 451-9031 9/8/2015
<br />CusroMErtNumeert 6111$52-001 GENERATowsREoismytot;#
<br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE
<br />2C. NO. OF
<br />20. VOLUME
<br />UN3291, Regulated Medical Waste, no a„
<br />62, Pon TE05 — 40 tial Tub (Bio) (5.3 Cu ft)
<br />CONTAINERS
<br />Cu Ft.
<br />6.2. PGII , un
<br />Mal Waste, .os,
<br />62 PGITB49 — 37 Gal Tub (Bi*) (4.9 Cu ft)
<br />Cu Ft.
<br />0
<br />6.23201, RegulatedMedkalWaste nos,
<br />62, PGII TE14 -+ 44 Gal Tub(Bio) (5.9 Cu #t)
<br />,. Cu Ft.
<br />UN3291.Regulated MWkAwaste,noz., TB21— (BT®) /TP15•- (Path) /TY15- (Chemo) 20 tial Tub (2.7CUFT)Cu
<br />Ft
<br />W
<br />W
<br />UN3201, Regulated Medical Waste, mos., iaB31- B
<br />62, PGII { io) /WP31— (Path) /WC31— (Chemo) 31 Gal Tub (4.14Ct1F
<br />)
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, nes.,
<br />62, PGII W842— (Bio)/FW43— (Path) /CW43— (Chemo) Gal Tub (5 , 7CUFT)
<br />Cu Ft.
<br />023281, Regulated Frei West% mo a.,
<br />62, PGII KRB — Biosystems Cardboard Box (4.2 cu ft)
<br />Cu Ft.
<br />i!
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6 $ PGII
<br />Cu Ft.
<br />UN3291, RegWalad Maidical Waste, n os.,
<br />8.2, PGII
<br />Cu Ft
<br />3. Generator's Certification: "1 hereby declare that the contents of tins consignment are fully and a ratsly TOTALS 0- •� Cb Ft
<br />described above by the proper shi ing name, and are ed, packaged, marked and labefledilpia®a ed, and
<br />are In�all respects In n proper o for transport according to applicable international and nab mnre lahons "
<br />_ — ... . _ ......— -
<br />,- —. ., -- ..
<br />Prkitedr yped Name a �n T stet
<br />4. TRANSPORTER 1 ADDRESS: Phone # (86 783-7422
<br />�u
<br />Stericycle, Inc. his is a Through shipment Applicable Permit Numbers:
<br />0
<br />4135 W. Swift Ave
<br />Hauler Reg# 3400
<br />CL
<br />Fresno,CA 93722
<br />paTRANSPORTER
<br />T9 ATI*7ecelpt o teal waste as des d abo
<br />PdnVrype Noma Signature Date
<br />B. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS Phone #
<br />N
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
<br />S. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone P.
<br />'S
<br />Applicable Permd Numbers:
<br />g°a m
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receilpt of medical waste as described above.
<br />Prlyd/Type Name Signature Date
<br />7. DI REPANCY INDICATION
<br />Transferred containers, , dr ft to : North Salt Lake, UT
<br />8A. Designated Facility: ®aB. Alremate Facility:
<br />EIM Altansate, Facility:
<br />80. Alternate Faclgty:
<br />,rt
<br />c.3 e, nc. :;tett ale. Inc.
<br />41 6 W. TQ'°' 90 N oocboro Dove
<br />Stericycle, Inc.
<br />1561 shetbm Drive
<br />Stericycle, Inc.
<br />3140 N 7th
<br />ua>
<br />ANN7: Oi TIS
<br />StreetMy
<br />I- F Sno,GA Nettle ettLek®, UT 841354
<br />Hollister, CA 98023
<br />Kansas city, ICs 68415
<br />W (8 )783-7422 (886)17 7422
<br />(866)783-7422
<br />(866)783-7422
<br />a TS ST22 SF,' a g 20 3VA,44 -36
<br />TS/08T 83
<br />TS/OST-28
<br />F. f received
<br />Pdnt/lype
<br />I
<br />r PACT ��Yce thayWrida
<br />b®enuthorized bqy the applicable state agency to accept untreated medical wastes and that I have
<br />above i dY �tes5tnc with the requirement outlined In that authorization
<br />e Signature Date
<br />Ta1'CaAG DOCUMENT
<br />
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