Laserfiche WebLink
T MEDICAL WASTE TRACKING FORM NUMBER <br />r� <br />o,-*- a S'CtE'If'1CyC1@ IN CASE pF EMERGENCY CONTACT: GHENITREG <br />• CUSTOMER NO. 21132 <br />1. Generator's Namra, Address and Telephone Number <br />GILL MEDICAL CENTER <br />163.7 N CALIFORNIA ST <br />STOCxTON, CA 95204— 6117 <br />(2110) ARI—RO31 11/24J2015 <br />CussoMert NUMBER G1ENERATOR's RrmsmAT= # <br />2A. DESCRIPTION OFWAST CONTAINERTYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291 Regulated Medical Waste, n <br />6.2 P611 110 GO Xub (Ria� <br />CONTAINERS.o.s., <br />Cu Ft. <br />Medical Waslo, a.o.s., <br />GI <br />Cu Ft <br />Regulated <br />02,UN3291 <br />r <br />UN3291Regulated Medical Waste, n.os., <br />R <br />6.2, PGiI <br />Cu <br />FF-- <br />a&2. <br />UN3291 <br />PG1� Regulated Medical Waste, n.o s., <br />T821— {BIO} /TPi5— {Path} jxY15— {Chemo} 20 sal Tub ( 2 •?Ct]FT) <br />OU R <br />W <br />UNS291 Regulated Medical Waste, n.os., <br />W <br />62, PGIIm—aM31 1 'Pub 14CUF <br />Cu R <br />UN P&I� Regulated Medical Waste, n.o.s., _ <br />Cu R <br />UN3291 Regulated Medial Waste, n.o s., <br />6.2, PGI <br />Cu R. <br />UN3291 Regulated Medial Waste, n.e.s . <br />6.2, PGII. <br />Cu R. <br />Cu Ft. <br />3. Generator's ertifictation: "I hereby dedwe that the contents of this consignment are fully and accurately TOTALS 110�- Cu FL <br />described by the proper shipping name, and are classified, packaged, marked and labelledlplacarded, and <br />all res Cts m proper condfUon for transport acoDrdfng to appli ab[e International and national overnmen regulations." <br />rin <br />')71&% $ ate, <br />iP led/TypedName <br />8. T NSPORTER 1 ADDRESS: Phone #. ( !! gp <br />F?aBV�umbesc 7 42 <br />Steriaycle, Inc. This is a Through Shipmenxt Applicable <br />0 <br />N <br />4135 V. Swift Ave Hauler Reg# 3400 <br />a <br />�r sena GA 93722 <br />TRANSPORTER RRTtFiGlM . Retrelpi ediCat waste as demob L <br />%e�0..Ptlnifiype <br />Name Signature Date <br />5. INTi_RMEDIATE HANDLER 2 tTRA SPORTER 2 ADDRESS: Phone #: <br />Fq <br />Applicable Permit Numbers' <br />r++ <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Reoelpt of medical waste as described above. <br />PrktVType Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 AODRESS• Phone # <br />Applicable Permit Numbers: <br />w <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Racelpt of medical waste as described above <br />x�s <br />— <br />Pr1nU7ype Name Signature Date <br />7.OISCREPANCY INDrAnON <br />Transferred containers cu ft to , North soft Lake, UT <br />no Faculty: 813. Alternate Facility: 8C. Alternate Facility. El 80. Attemate Factiity: <br />cs <br />Ste Sts le, inc. Sttericycte, Inc. Sterlcycle, inc. <br />413 W. SwiftAvOUTOCLAV 90 oro Drive 1651 Shelton Drtva 3140 N 7th Siraettrfy <br />w <br />Fre no. CA a E ANNE O Tl North S It Lake, UT 84064 Hollister, CA 06023 Kansas City, KS 66118 <br />(86 783-422 866)78 7422 (866)783-7422 (866)783-7422 <br />TS/ S 3A448 36 TWST 83 1VOST 26 <br />NOV 2 4 2015 �. <br />� <br />TREATM NT'FVLITY: I certify that I have been uthorized by the applicable state agency to accept untreated medical wastes and that i have <br />I- <br />received t e�6�iye Indicated wastes in accordan with the requirement outlined in that authorization. <br />a.. <br />PrinMpe me Signature Date <br />