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*®* Stel'tC Cl@• IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.4249300 <br />U ON.* <br />.mss ►�,e amu- Route #: 023 — 17 CUSTOMER NO. 21132 <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1617 N CALIi'CRNIA ST <br />STOCKTON, CA 35204- 6117 <br />�I IIIdII�NIIIq�I�IHllldll�tll <br />St@riCjyGl@, Inc. <br />1551 Shelton Drive <br />Holllt;<ter, CA 95023 <br />t866j783-7422 <br />(204) 451-9031 <br />CusTOMERNUMBER M1$52-001 GEJERAno'sREammAnoN# <br />ZA. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF <br />CONTAINERS <br />W UN3291, Regtuated MGM] wasre. oaa., -A i 'n -1k 04 o} {S 9 cu #4-1 <br />® 6 <br />U <br />6 <br />W <br />5 U <br />Phone # <br />Applicable <br />uP13291, bed <br />82, PGI! <br />UN328i, Regulated <br />s 2. Pcn <br />'t`B34 4 60L { <br />nos., T823- {BZQ} /TP35- (Path)%TY35- (Chemo) 20 t#a3, Tub {2.7Ct1F <br />n.o.s., Ui831- (Bio)/6fi?31- {Patti} /WC31- (Chemo) 31 Gal Tub {4 .19Ct <br />noe, <br />teIB63- {Bio}IP6dti3— {Path} iCimrtt3- {chemo} Gal Tub {5.?t:t>Px} <br />fl.o.6., <br />»!tB - Biosystems Cardboard Box ( <br />4.2 cu it:) <br />nas, <br />h.0.e., <br />Se 9PedITyped <br />s Certification <br />"i hereby declare that the contents of this consignment are fully and accurately I TOTALS �► � 4 <br />d va by the proper shipping name, and are classified, packaged, marked and tabeAedlplacarded, a d r• <br />a <br />2"! ®cls In proper cronditwn for transport aoxrding to applrt�ble international and naddnal _ ^ m Cal regulations." <br />Name --1 J tu y"f dl�'46 Si �nw <br />tur y <br />S. INTERMEDIATE HANDLER 2 i TRANSPORTER 2 ADDRESS: Phone # <br />N <br />AppOcable Permit Numbers: <br />f <br />INTERMEDIATE HANDLER/ TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, i <br />Prtntttype Name Signature <br />9129l2Q15 <br />Cu Ft <br />Cu Ft <br />Cu Ft <br />Cu Ft. <br />Cu Ft <br />Gu Ft. <br />Cu Ft <br />CU <br />Ft <br />r' <br />Cu Ft <br />ri, Ft <br />containers, cu <br />nwh,ra . _—.--- -- -.- Hata <br />.. <br />Date <br />8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: <br />� INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />I PdnriM1mw Na <br />me---_-..-__t$Innwh,ra <br />' <br />authorized by the applicable state, agency to accept untreatedmtedical wastes and that I have <br />with, the requirement outlined in that authorization. <br />®Signature <br />7. DISCREPANCY INDIGATIQN <br />Il <br />15 ¢CL/%.,E a <br />Ff'@enC A ISE. d� 2T'Z IV <br />(t368)71�� {F <br />TsrosT� 3� <br />,TMENr FACILITY: t minify that I have <br />t 1�3i7 YY. V <br />ed the ab v i dfS3ited 4 s, fn acxa <br />n.eee.. <br />[E - <br />Permit Numbers: <br />� 5PQRTER 1 ADDRESS: l Phone# (666) 783-7422 <br />3tet:icy'cle, Inc. ® This is a Through shipment <br />re 4135 A. Swift Ave Applicable Pemtd Numbers: <br />aN Ft:earto, iii. 93722 ' Hauler Reg# 3400 <br />Jy TRANSPORTS / TIIFICA�'iON f ae deaanbePAntrnmwNwmn_( �te <br />Date <br />ft to :North Salt Lake, UT <br />nate FaatlUy: <br />yyCl@, Inc. <br />F4Xbt31'0 DTIV@ <br />Sett i.klke, UT 8 <br />1054 <br />TS/OST 63 <br />SberiGyrGl@, Inc. <br />3140 N 7th Str@ettrly <br />Kansas City, K3 tat"s i i 5 <br />(856)T83-7422 <br />TW <br />Date <br />