Laserfiche WebLink
®® ®® Si+ telriC RQ- INCASE OF EMERGENCY CONTACT: CHEMITREC 1-800-424-9300 <br />Route #: 023 - 7 CUSTOMER NO. 21132 MDFROOGXV5 <br />1. Generator's Name, Address and Telephone Number 11111111111111 111ATTN: IN111 <br />GILL MEDICAL CENTER <br />1617 N CAL:ElrCRNIA ST <br />STOCKTON, CA 95204- 6117 <br />(209) 451-9031 9/22/2015 <br />Cus,romER NUMBEft 611852--001 GENmAwwsResismTtoN9 <br />f2A. DESCRIPTION OF wASTIt 2S. CONTAINER TYPE 2C. NO. OF 2D. VOLUME <br />UN i Regulated Medi Write,rkos, TBOS - 40 Gal Tub (Bio) (5.3 cu ft) coNVAtNt=_Rs <br />62, Cu <br />UN3291, Replated MedW Wasl% n4 s„ TB4 9 — 37 Gal Tub (Bio) (4. 9 cu ft) <br />6.2, PGO Cu.Ft <br />UN3281, Regtdated Medical waste, nos., TB14 — 44 Gal Tub (Bio) (5.9 Cu ft) <br />p 6.2, PGO Cu Ft. <br />UN329 I Regtdated Medical waste, n o 8, TB21— (BIO) TP15— (Path) TY15— (Chemo) 26 coal Tub (2.7CUFT) <br />SCu F1 <br />UJI UN3291, Regulated Medbal Wim, nog. W831.- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal flub (4.14CUF <br />tZ 6.2, PGiI Cu Ft. <br />Medical waste, no.s„ WB43- (Bio) /PW43- (Path) /Cit43- (Chemo) Gal Tub (5.7CUFT) <br />6.2, PGiI Cu Ft. <br />UN3201, Regulated Medical Whste, n e s„ XAB — Biosystems Cardboard Boar (4.2 cu ft) <br />6.2, PGII Cu FL <br />UN329l, Regufeled Medicai Whsle, nos„ <br />62-201 Cu FL <br />UN329l, <br />I _�ksl Wtenos. <br />62, PGII <br />Cu Ft. <br />3. ene2ab' <br />ortification., "I hereby declare that the contents of this consignF!Sign2eture! <br />ccurately I TOTALS ®I I Q C <br />s4eby the proper shipping name, and are classified, packaged, mared, andare in ais in piper conditionfor ransportaxo�mg toapp [cable interaovernments regulationsPried Name — ure _ Tµpa 1 61 <br />a a, D3AAPORTER1RE s: Phone " (66 -74 2 <br />S' DeC%gale, Inc. Thar. 1 h Siu-pment Freano,GA 93722 Applicable Permit Numbers: <br />4135 Swift Ave Hauler Reg# 3400 <br />a, TRANSPORT TIF CAT Recut of medical waste as dosed a s. <br />Prinfllype Name Signature Fate <br />3. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone M <br />w Applicable Permit Numbers <br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Ptlnt/Type Name Signature Data <br />+"6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0: <br />Applicable Permit Numbers: <br />a 3 INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />a7 PrIntlType Name Signature Date <br />/. Ur.7lsKCCWtlIsY IIVViWiI rVly <br />Transferred containers, <br />t .. <br />Inc. <br />ORTIZ <br />�.. SEP 2 2 <br />X015 <br />MENT FACILITY. I certify that I <br />J Steov� in Icated wastes in <br />/�- A* <br />w <br />Steric ycle, inc. <br />90 N. Foxboro Drive <br />Rrth Salt Latae, UT 84454 <br />Cu ft to : North $aft Lake, UT <br />C. Altsmate Facility <br />80. Aitamate Faeillty: <br />1 6f 5habn <br />Drive <br />3140 N�7th. Sir et <br />Holbleer. CA 95023 <br />Kansas Cly, KS 66115 <br />(866)783-7422 <br />(866)7M7422 <br />MOST 83 <br />TWOST-26 <br />been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />Mance with the requirement outlined in that authonzation. <br />Signature Date <br />t -t , .t -l. , , DOCUMENT <br />