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®®•�• Sterwcycl@` IN CASE OF EMERGENCY CONTACT CHEMTREC 1.800 124-9300
<br />e owba . e. reaw; Route 0: 123 — 18 CUSTOMER NO. 21132
<br />1. Generator's Name, Address and Telephone Number
<br />Ai N:
<br />GILL MEDICAL CENTER
<br />1617 N CALIF 'ROAR ST
<br />STOCKTON, CA 95204— 6117
<br />CUSTOMErt NUMBER 611185
<br />2A. DESCRIPTION OF WASTE 2H.
<br />UN3291, Regulated Medical Waste, n o s.,
<br />82, PGiI
<br />LIN3291, Related Medical Waste, me a,
<br />82, PGII
<br />1% UN3291, Regulated Medceal Waste, no a.,
<br />® 8.2, PGII
<br />UN3291, Reguiated Medica Waste, n.o s.,
<br />82, PGII
<br />W UN3291, Regulated Medical Waste, n o a,
<br />tZ 82, PGII
<br />� UN3291, Ragulated Medical Waste, n o s
<br />9 2, PGiI
<br />UN3291, Regulated Medical Waste, nas.,
<br />82, Pell
<br />UN3291, Regulated Medd Waste, n os ,
<br />82, PGII
<br />UN3291, Regulated Madacal Waste, n.o a.,
<br />FMITTIT40METim
<br />ii�isiioitimam'uneei0u
<br />(209) 451-9031
<br />-001 Ge irmmows Remem mom #
<br />CONTAINER TYPE
<br />TB05 — 40 tial Tub (Bio) (5.3 an ft)
<br />TB49 — 37 Cal Tub (Rio) (4.9 cu ft)
<br />T914 - 44 Gal Tub(Bia) (5.9 Cu ft)
<br />WB31- (Bio) /WB31— (Path) /WC31— (Chem®) 31 tial Tub (4.14Ct
<br />WB43—(Bio)/PW43—(Pat:h)/CW43—(Chemo) tial Tub(5.7CUPT)
<br />XRB — Biosystems Cardboard Box (4.2 cu ft)
<br />,2 PGII 1
<br />3. Generator's Certification: "i hereby declare that the contents of this consignment are fully and accurately
<br />described above by the proper shipping name, and are c1milled, packaged, marked and labelled/placarded, i
<br />siMall respects in proper condiftlor transport a2�Frdmg to appNrcabieinterla"anal and nations
<br />aV.TRANSPORTER 1 sterlcycle, Inc.
<br />�u 4235 1. Swift Ave
<br />aIrreann,CA 93722
<br />N
<br />a TRANSPORTER CERTIFIC P, : Real t of medial waste as
<br />PnnUType Name Slgneha
<br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />13 This is a
<br />TOTALS ►
<br />agalabons."
<br />11/10/2015
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />Cu Ft.
<br />Cu Ft
<br />I
<br />Cu FL
<br />Cu Ft
<br />Cu Ft
<br />Cu Ft.
<br />Cu R
<br />phone #. (Ubb) 115.5-1QZ1
<br />Applicable Pennd Numbers•
<br />11auleir Reg* 3400
<br />Date /_/ ` ..
<br />Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printriype Name signature Date
<br />8. INTERMEDIATE HANDIER 31 TRANSPORTER 3 ADDRESS: Pule V
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />—
<br />Print/Type Name Signature Date
<br />Print/Type Name
<br />Tfaneftfimad corda11tem, tar 2 to : North Salt Lake, UT
<br />Inc. Stertayt:le. Inc.
<br />efAt DrIve
<br />TOCLAV>; North oxbor
<br />ts , UT M54
<br />LE ANNE OR iz (066)7#7422
<br />SterIcycle.Inc.
<br />1561 Shelton Drive
<br />Holllster, CA 955023
<br />(866)783-7422
<br />TWOST 83
<br />8D, Alternate Facility:
<br />Steri e, Inc.
<br />814® 7th StmetW
<br />Kansas WKS 88115
<br />(86783-7422
<br />_28
<br />NOV 10 2094 j 1
<br />rII.iTY: I certify that 1 have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />e Indicated wastes in accordance with the requirement outlined In that authorization.
<br />Signature Date
<br />ORIGUIell. 77 DOCIMENT
<br />
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