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<br />tericyCIQ° IN CASE OF EMERGENCY CONTACT. CHEMTREC 1.800.424-9300
<br />ft0 Route #: 123 — 9 CUSTOMER No. 21132 MDF'ROOH5K4
<br />1. Generator's Name, Aplpddress and Telephone Number
<br />A8p,-.
<br />GILL MEDICAL CE
<br />1617 N CALXFORNIA ST
<br />STOCKTON, CA 95204- 6117
<br />UN3291,
<br />6.2, PGII,
<br />UN3291,
<br />6.2, PGII
<br />UN8291,'
<br />&2, PGII
<br />nos ,
<br />nos.,
<br />n o.s,
<br />1111111111111111111111111111111111111111111
<br />) 451-9031
<br />GENERAToR,s REalsTRATiou #
<br />CONTAINER TYPE
<br />TBOS - 40 tial Tub (Bic) (5.3 Cu it)
<br />T849 - 37 Gal Tub (Bic) (4.9 cu t:t)
<br />TB14 - 44 Gal Tub (Bio) (5.9 cu t:t)
<br />T1321—(13x0)/TPIS-(Path)/TYIS-(chemo)20 tial Tub(2.?CUFT)
<br />WB31-(Bio)/64931-(path)/WC31-(Chemo)31 Gal Tub(9.19CUET
<br />wBSI3- (Bio) /PW43- (Path) /Cts43- (chemo) Gal Tub (5.7CUFT)
<br />XRB— - biosystems Cardboard Box (4.2 cu ft)
<br />a certiiication: I hereby declare that the contenis of this consignment are fully and
<br />ve by the proper shipping name, and are classified, packaged, marked and Iabellet!4
<br />rCts to proper "
<br />34 forsport accordblg to applicable International and nations
<br />c/ % P ntedfTyped Name
<br />a SPORTER 1 ADDRESS:
<br />Ste>ricyCle, ins.
<br />a 4335 W. swift: Ave
<br />0. Fresno,CA 93722
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as
<br />Pdnt/Type Name --,??4 Signatut
<br />11/17/2015
<br />CUSTOMER NUMftR (511,
<br />2A. DESCRIPTION OF WASTE
<br />2D. VOLUME
<br />Cu Ft
<br />UN329i, Regulated Medhaf waste,
<br />6.2, PGII
<br />UKWOI, Regulated Medical Waste, n ox,
<br />Cu Ft.
<br />Printlrype Name Signature
<br />8.2, PGII
<br />I%
<br />UIV32a1, Regulated MSI waste, n.o s.,
<br />Q
<br />8.2, PGII
<br />UNMt, Regulakid waste, n o s.,
<br />6.2, PGII
<br />Ili
<br />UNWI, Regulated Medical Waste,
<br />l
<br />LU
<br />LU
<br />6.2, PGO
<br />UNMI, Reaulated Madkel Wade, n.o s.,
<br />UN3291,
<br />6.2, PGII,
<br />UN3291,
<br />6.2, PGII
<br />UN8291,'
<br />&2, PGII
<br />nos ,
<br />nos.,
<br />n o.s,
<br />1111111111111111111111111111111111111111111
<br />) 451-9031
<br />GENERAToR,s REalsTRATiou #
<br />CONTAINER TYPE
<br />TBOS - 40 tial Tub (Bic) (5.3 Cu it)
<br />T849 - 37 Gal Tub (Bic) (4.9 cu t:t)
<br />TB14 - 44 Gal Tub (Bio) (5.9 cu t:t)
<br />T1321—(13x0)/TPIS-(Path)/TYIS-(chemo)20 tial Tub(2.?CUFT)
<br />WB31-(Bio)/64931-(path)/WC31-(Chemo)31 Gal Tub(9.19CUET
<br />wBSI3- (Bio) /PW43- (Path) /Cts43- (chemo) Gal Tub (5.7CUFT)
<br />XRB— - biosystems Cardboard Box (4.2 cu ft)
<br />a certiiication: I hereby declare that the contenis of this consignment are fully and
<br />ve by the proper shipping name, and are classified, packaged, marked and Iabellet!4
<br />rCts to proper "
<br />34 forsport accordblg to applicable International and nations
<br />c/ % P ntedfTyped Name
<br />a SPORTER 1 ADDRESS:
<br />Ste>ricyCle, ins.
<br />a 4335 W. swift: Ave
<br />0. Fresno,CA 93722
<br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as
<br />Pdnt/Type Name --,??4 Signatut
<br />11/17/2015
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />M. NO. OF
<br />CONTAINERS
<br />2D. VOLUME
<br />Cu Ft
<br />Cu Ft
<br />CU Ft
<br />Cu Ft.
<br />Printlrype Name Signature
<br />Cu FL
<br />«,
<br />Cu Ft
<br />Phone #:
<br />CU Pt
<br />Cu Ft.
<br />Cu Ft
<br />_
<br />- ° Phone #: (860T83-7422
<br />® This is a Through Shipment Applicable Permit Numbers:
<br />r Hauler: Reg# 3400
<br />►: c
<br />'a
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #.
<br />gApplicable
<br />permit Numbers-
<br />INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printlrype Name Signature
<br />Date
<br />«,
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers -
<br />INTERMEDIATE HANDLER / TRANSPORTER CIERTIFICATiON: Receipt of medical waste as described above.
<br />—
<br />PdnUType Name Signature
<br />Data
<br />7. DISCREPANCY INDICATION
<br />Transferred cantatners, cu h to : North Oak Lab,
<br />UT
<br />8A. Designated Facility: 813. Alternate Facility: 8C. Alternate Faclilty:
<br />®BD. Alternate Facility:
<br />QSteri
<br />is
<br />le, Inc. Steil e, Inc. Sterlcycle, Inc.
<br />413 90 N. Fo*oro Drive 1561 Sheitcn Drive
<br />Stedcycle. Inc.
<br />3140 N 7th Streettry
<br />Fre no,CA 987211(1T0 ;(„AVC o k Lake, UT 84/154 Hoigatar, CA 98023
<br />Kaneaa Ciiy, KS 6611 S
<br />(t36 )783.74I LE ANNE QR 8166)7 e866}7 3-7422 (/366)783-7422
<br />(866)789-7422
<br />TS OST22 3A-44 36 TSIOST 83
<br />TS/OST 26
<br />TREAT
<br />NOV1��
<br />ENTF� CILIOV I 1 have
<br />certif}�"th bee authorized by the applicable state agency to accept untreated
<br />I- receive th® bo'r/e Indicated wastes in accorda ce with the requirement outlined in that authorization.
<br />medical wastes and that I have
<br />In
<br />' """"'
<br />PrinVryp
<br />Name Signature
<br />Date
<br />. C}
<br />ORIGINAL TRACKING DOCUMENT
<br />
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