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Pdnt/Type Name Signature Date
<br />6. INTERMEDIATE MANDLER 2 /TRANSFFORTER 2 ADDRESS. 1 Phone #.
<br />1 i Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as deatxmtaed above. ,
<br />PdnUlype N_ SWaature Date
<br />n 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />Applicable Permit Numbers:
<br />aa. ll INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdntltype Name Signature Date
<br />I 17. DISCREPANCY INDICATION
<br />TmillsbMilt C01981 , _
<br />Facility: ®8$, Altornate Facility:
<br />e- Inn- cycle. Inc.
<br />4.136 W. 8V9t..AVE 0 N•.. F�ao am Drive ®� * .�
<br />t=r* —to
<br />Saeii Lake, Lff S4M
<br />®�. �lE ORT1Z
<br />--OCT 0 6 2015
<br />T FACILITY: I certify thAl I
<br />=19icated nstes In
<br />{
<br />o1 R to : North Sant Lake, UT
<br />8C. Alternate Facility:
<br />SW ccyyccle, Inc.
<br />1561 Shelton DM
<br />Wilder, CA S150=1
<br />(6")783-7422
<br />TSIOST 83
<br />81). AftemMe Facility:
<br />Stericycle, Inc.
<br />3140 N 7th et*
<br />Kansas Cky, KS S611S
<br />(866)783.7422
<br />TS/OST 26
<br />been authorized by the applicable state -agency to accept untreated medical wastes and that I have
<br />dance with the requirement outlined In that authorization i
<br />Signature Date
<br />ORIGINAL TRACIONG DOCUMENT
<br />N
<br />® SteIN IN CASE OF EMERGENCY CONTACT. CHEMTREC 1.800.4249300
<br />®'® '""B�"'` Route f: 023 -- 6 CUSTOMER NO. 21132
<br />MDFROOGZTO
<br />1. Generator's Name, Address and Telephone Number on
<br />ATTN: ff I
<br />GILL MEDICAL CE
<br />1617 N CALIFORNIA ST
<br />STOCRTON, CA 95204- 6117
<br />203 451-9031
<br />3.0/'6/2015
<br />CUe3OMER NUMBER -003 GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE 28, CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n o.s.,
<br />CONTAINERS
<br />62,PIII TBOS — 40 Gal Tub (Bio) (5.3 cu ft)
<br />Cu Ft
<br />UN3291. Regulated I Waste, p".62,
<br />PGII T049 — 37 Gal. Tub (Bio) (4.9 cu tt)
<br />Cu Ft
<br />Memat nae..
<br />CJ7
<br />Qt1N3291,ROWAW
<br />62, — 44 Gal Tub (Bio) (5.9 Cit tt)
<br />62, Pini
<br />Cu Ft.
<br />6.2 PG11 N329, RegWaW Medical Waste, n TB21- (BIO)/TP1S— (Path) /TY15— (Ch+emo) 20 Leal Tub (2.7CUFTI
<br />Cu FL
<br />III
<br />UN329f,Regulated Med Waste, noxa,
<br />U. Poll WB31- (Bio)/WP31- (Path)/WC31- (Chemo)31 Gal Tub (4.14C
<br />y
<br />Cu Ft
<br />LU
<br />U,
<br />UN3291, Regulated Med We ,, nA.s.,
<br />62, Poll UB43— (Bio /PW43— Path /CW43— Chemo) Gal Tub (5.7CUFT)
<br />Cu Ft
<br />UN3291, Regulated Medical Wade, nos„
<br />6,2, Pell KRE — Bio stems Cardboard Box 4.2 Cu ft
<br />Cu FL
<br />UN3291; Raguloted Medical Waste, me s.,
<br />62, PGG
<br />CNN Ft.
<br />UN3291, Regulated Medical Waste, n.o.a,
<br />62, PGS
<br />Cu Ft.
<br />11 TOTALS ►
<br />3. Generator's Certification: hereby declare that the contents of this consignment are fully artd accurately
<br />Cu Ft
<br />descrl ed above by the pr steer shipping Hama, and are ctasstfled, packaged, marked and labelladtplacaMed, and
<br />a n I respects in proper c�nd{tion for transport according to applicable tntem�aganai and natio Egovemmental regulations."_�
<br />l rintedfl'yped Name Signatu �
<br />to
<br />4. IyANSPORTER 9 ADDR SS:
<br />Phone # (S®7422
<br />3,
<br />Stericycle, Inc. Th3.a a Through shipment
<br />Pernut
<br />Applicable Peut umbers:
<br />4195 W. Swift Ave
<br />Eauler Reg# 3400
<br />a.W
<br />Fresno,CA 93722
<br />na.
<br />TRANSPORTER RTIFICATIO tpt of medical waste as descn a
<br />Pdnt/Type Name Signature Date
<br />6. INTERMEDIATE MANDLER 2 /TRANSFFORTER 2 ADDRESS. 1 Phone #.
<br />1 i Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Receipt of medical waste as deatxmtaed above. ,
<br />PdnUlype N_ SWaature Date
<br />n 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone M
<br />Applicable Permit Numbers:
<br />aa. ll INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdntltype Name Signature Date
<br />I 17. DISCREPANCY INDICATION
<br />TmillsbMilt C01981 , _
<br />Facility: ®8$, Altornate Facility:
<br />e- Inn- cycle. Inc.
<br />4.136 W. 8V9t..AVE 0 N•.. F�ao am Drive ®� * .�
<br />t=r* —to
<br />Saeii Lake, Lff S4M
<br />®�. �lE ORT1Z
<br />--OCT 0 6 2015
<br />T FACILITY: I certify thAl I
<br />=19icated nstes In
<br />{
<br />o1 R to : North Sant Lake, UT
<br />8C. Alternate Facility:
<br />SW ccyyccle, Inc.
<br />1561 Shelton DM
<br />Wilder, CA S150=1
<br />(6")783-7422
<br />TSIOST 83
<br />81). AftemMe Facility:
<br />Stericycle, Inc.
<br />3140 N 7th et*
<br />Kansas Cky, KS S611S
<br />(866)783.7422
<br />TS/OST 26
<br />been authorized by the applicable state -agency to accept untreated medical wastes and that I have
<br />dance with the requirement outlined In that authorization i
<br />Signature Date
<br />ORIGINAL TRACIONG DOCUMENT
<br />
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