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®®�®� 5tQr{Cyc�Q- IN CASE OF EMERGENCY CONTACT: CHEMTREC 9.800424.9300
<br />••' Pattonnm Ma ssxn Route #; 023 10 CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number
<br />ATTNz
<br />GXLL MEDICAL CE
<br />3:617 N CALIFORNIA ST
<br />STOCKTONt CA 95204- 6117
<br />451-9031
<br />852-001 GENERATOR'S REWSTRATION
<br />28. CONTAINER TYPE
<br />TBDS — 40 Gal Tub (Rio) (5.3 Cu ft)
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TB14 — 44 Gal Tub(Bio) (5-9 cu ft)
<br />TB21-(BIO)/TP15-(Path)/T'Y15-(Chemo)20 Gaal Tub(2.
<br />MB31-(Bi.o)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.
<br />VB42- (Bio) /PM43- (Fath) /CV43- (Chemo) Gal Tulb (5. W
<br />3. Generatorlq Certification: "I hereby declare thet1the contents of this consignment are fully and
<br />djrftbed abo a by the proper shipping name, and are classified, packaged, marked and labelled/I
<br />Are In all reepActs in proper condition for transport according to applicable international and nations
<br />i
<br />10/20/2015
<br />!C. 140. OF 2D. VOLUME �.
<br />CONTAINERS
<br />Cu Ft
<br />Cu Ft
<br />Cu FL
<br />Cu FL
<br />Cu Ft.
<br />v
<br />CUSTOMER NUMBER
<br />2A. DESCRIPTION OF WASTE
<br />Phone" (866) 783-7422
<br />UN3291, Regulated Medial Waste, nes.,
<br />This i hrough Shipment
<br />6.2. PGII
<br />UN3291, Regulated Medical Were, n o.a ,
<br />4135 V. Swift Rice
<br />Ft:esn®,CA 93722
<br />6.2, PGII
<br />UN3291, Regulated Medical no.a..
<br />TRANSPORTER C RTIFICATION• pt Of med aste as des d
<br />Q
<br />6 z PGiI
<br />UNMI, Regulated Medical Wee, nos..
<br />f
<br />6.2, PGII
<br />UN3291,Regulated Medieai Waste, n o a.,
<br />W
<br />1Z
<br />5
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, mo a.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n it s.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n ox,
<br />6z, PON
<br />UN3291. Regulated Medical itfeste, n o a,
<br />451-9031
<br />852-001 GENERATOR'S REWSTRATION
<br />28. CONTAINER TYPE
<br />TBDS — 40 Gal Tub (Rio) (5.3 Cu ft)
<br />TB49 — 37 Gal Tub (Bio) (4.9 Cu ft)
<br />TB14 — 44 Gal Tub(Bio) (5-9 cu ft)
<br />TB21-(BIO)/TP15-(Path)/T'Y15-(Chemo)20 Gaal Tub(2.
<br />MB31-(Bi.o)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.
<br />VB42- (Bio) /PM43- (Fath) /CV43- (Chemo) Gal Tulb (5. W
<br />3. Generatorlq Certification: "I hereby declare thet1the contents of this consignment are fully and
<br />djrftbed abo a by the proper shipping name, and are classified, packaged, marked and labelled/I
<br />Are In all reepActs in proper condition for transport according to applicable international and nations
<br />i
<br />10/20/2015
<br />!C. 140. OF 2D. VOLUME �.
<br />CONTAINERS
<br />Cu Ft
<br />Cu Ft
<br />Cu FL
<br />Cu FL
<br />Cu Ft.
<br />v
<br />a`
<br />S. INTERMEDIATE HANDLER 21 ThANSPORTER 2 ADDRESS' Phone 0
<br />119 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER t TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnUType Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPO TER 3 ADORES& Phone M,
<br />5 9 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdnt/rype Name signature Date J
<br />1 17. DISCREPANCY INDICATION
<br />Transferred containers,
<br />Facility: ® 63. Alterate Facility:
<br />3, Inc. S6ericycle, inc.
<br />SA114 "•'" F046ro Drive
<br />A o2MTOCLAVE North Saft Lake, UT 84064
<br />-14AE ANNE OR lZ (86s) s3 -742a
<br />TREAT ENT arI I 2 ce l� at t have
<br />received th . a indicated Waste/s� I,n� acro
<br />PrInUType ams
<br />cu ft to : North Sah Lake, UT
<br />Stericycle. Inc,
<br />1651 Shettcn Drive
<br />Hollister, CA 56023
<br />(886)783-7422
<br />TSIOST 63
<br />Stericycle, Inc.
<br />3140 N 7th Streettrty
<br />Kansas City, VS 86if6
<br />(866)783-7422
<br />TSIOST 26
<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 />i' ORIGINAL TRACKING DOCUMENT
<br />Date
<br />PORTER I ADDRESS:
<br />®---®"
<br />Phone" (866) 783-7422
<br />SteriCyCAe l InC a
<br />This i hrough Shipment
<br />Applicable Permit Numbers.
<br />10,
<br />W
<br />4135 V. Swift Rice
<br />Ft:esn®,CA 93722
<br />Hauler Reg# 3400
<br />n. Z
<br />TRANSPORTER C RTIFICATION• pt Of med aste as des d
<br />PrInVrype Name Sigrmature
<br />Data
<br />a`
<br />S. INTERMEDIATE HANDLER 21 ThANSPORTER 2 ADDRESS' Phone 0
<br />119 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER t TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnUType Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 / TRANSPO TER 3 ADORES& Phone M,
<br />5 9 Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Pdnt/rype Name signature Date J
<br />1 17. DISCREPANCY INDICATION
<br />Transferred containers,
<br />Facility: ® 63. Alterate Facility:
<br />3, Inc. S6ericycle, inc.
<br />SA114 "•'" F046ro Drive
<br />A o2MTOCLAVE North Saft Lake, UT 84064
<br />-14AE ANNE OR lZ (86s) s3 -742a
<br />TREAT ENT arI I 2 ce l� at t have
<br />received th . a indicated Waste/s� I,n� acro
<br />PrInUType ams
<br />cu ft to : North Sah Lake, UT
<br />Stericycle. Inc,
<br />1651 Shettcn Drive
<br />Hollister, CA 56023
<br />(886)783-7422
<br />TSIOST 63
<br />Stericycle, Inc.
<br />3140 N 7th Streettrty
<br />Kansas City, VS 86if6
<br />(866)783-7422
<br />TSIOST 26
<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 />i' ORIGINAL TRACKING DOCUMENT
<br />Date
<br />
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