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St et"1C�/CI@ IN CASE OF EMERGENCY CONTACT CHEMTREC 1-808.424-9380
<br />PmodragPeopla,Re6.digRk4: Routs #S 023 - 17 CUSTOMER NO. 21132 MDFROOH20
<br />1. Generator's Name, Address and Telephone Number
<br />A 8p€ 1 iY •s
<br />GILL MEDICAL CENTER
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204-- 6117
<br />(209) 451-9031
<br />10/27/2015
<br />4. TRANSPORTER I VoMmycle,, Inc. Lj This :LA,, a T ugh Shipment Phone#
<br />4135 a. swift Ave � 'pVu1W%uWr!3400
<br />Fceeno,CA 93722
<br />M 2 TRANSPORTS ERTI ICATI t t fat waste as•d d e60p--7-
<br />5.
<br />dntliype Name Signture Date INTERMEDIATE HANDLER / TRANSPORTER 2 ADDRESS: Phone#;
<br />ApPllable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medial waste as described above.
<br />Printrfype Name Signature Date
<br />n
<br />S. INTERMEDIATE HANDLER 3 f TRANSPORTER 3 ADDRESS: Phone #:
<br />:3 Applicable Permit Numbers
<br />a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />f
<br />PrintlType Name Signature I Date
<br />4136 W. 9
<br />Fresno,CA
<br />(866)783-7
<br />TS/09T22
<br />TREATMENT FACT
<br />received the above
<br />Print/Type Name —
<br />:Ice
<br />Transferred containers, cu R to : North Sail Lake, UT
<br />CUSTOMER NUMBER 6111852-001 GENERATAR'sREOISTRMON#
<br />® Be. Aitemeto Facility:
<br />2A. DtSCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.OF
<br />2D. VOLUME
<br />.
<br />UN3291, R Medal Waste, n o a, TB05 — 40 Coal Tub (Bio) (5.3 cu tt)
<br />Stericycle, Inc.
<br />Stericyde, Inc.
<br />aPGII
<br />Cv F1
<br />1661 Shelton Clive
<br />UN3291,Regulated Medical Waste, noa, TB49 - 37 Gal. Tub (Bio) (4.9 cu ft)
<br />DALE
<br />NN Lake. 84054
<br />6 2, PGII
<br />Cu Ft
<br />W6.2
<br />91, Regulated Medical Waft n o s., TB14 — 44 Gal Tub (Bio) (5.9 cu 2t)
<br />(868)783-7422
<br />(866)783-7422
<br />OCT
<br />e Cu FL
<br />TS/OST s3
<br />UN3291, Regulated Medical Waste, n o a., a — o)20 Gal 2
<br />62, PGII
<br />Cu FL
<br />W
<br />UN329 , Regulated Medial Waste, n.o.a, WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUF )
<br />62. PGII I
<br />Cu Ft.
<br />emtedulaMedal Waste, n os., UB43— (B7i.o) /PW43— (Path) /CW43— (Chemo) Gal Tub (5.7CUFT)
<br />6 PGII
<br />UN3291,Regulated Medical Waste,nos„ KRB-- 13iosysttems Cardboard Box (4.2 cu it)
<br />62, FellCu
<br />Ft
<br />UN3291. Regulated Medecal Waste, n o s ,
<br />6.2, PGII
<br />Cu FL
<br />UN3291, Rotated Medial Waste, n o a,
<br />a 2, PGIl
<br />Cu FL
<br />cribe above by the proper shlpping name, and are classlAed, packaged, and labeUedi Med, d
<br />F/3 rator's Certification: 'I hereby declare that the; contents of this consignment are fully and ac curatel Cu FL
<br />In ail r specs In proper condition for transport accordina to applicable Intemational and nali i govemm tai regulabons " ,
<br />4. TRANSPORTER I VoMmycle,, Inc. Lj This :LA,, a T ugh Shipment Phone#
<br />4135 a. swift Ave � 'pVu1W%uWr!3400
<br />Fceeno,CA 93722
<br />M 2 TRANSPORTS ERTI ICATI t t fat waste as•d d e60p--7-
<br />5.
<br />dntliype Name Signture Date INTERMEDIATE HANDLER / TRANSPORTER 2 ADDRESS: Phone#;
<br />ApPllable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medial waste as described above.
<br />Printrfype Name Signature Date
<br />n
<br />S. INTERMEDIATE HANDLER 3 f TRANSPORTER 3 ADDRESS: Phone #:
<br />:3 Applicable Permit Numbers
<br />a INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above.
<br />f
<br />PrintlType Name Signature I Date
<br />4136 W. 9
<br />Fresno,CA
<br />(866)783-7
<br />TS/09T22
<br />TREATMENT FACT
<br />received the above
<br />Print/Type Name —
<br />:Ice
<br />Transferred containers, cu R to : North Sail Lake, UT
<br />® Be. Aitemeto Facility:
<br />8C. Altorriate Facility:
<br />n 8D. Alternate Facility:
<br />Stericycle, Inc.
<br />Stericyde, Inc.
<br />AU0'—
<br />l—FmorC
<br />1661 Shelton Clive
<br />8140 N 7th Weettffy
<br />DALE
<br />NN Lake. 84054
<br />Hollister, CA 95023
<br />Kansas City, KS 66115
<br />(8 783- 422
<br />(868)783-7422
<br />(866)783-7422
<br />OCT
<br />2 7336
<br />TS/OST s3
<br />TS/48T 26
<br />rc
<br />lieby the applicable state agency to accept urjtreated medical wastes and that I have
<br />the quirement outlined in that authorization.
<br />v! 'CANAL IML;rjNL-j L UL;UIVICiN11
<br />Date
<br />
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