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5. INTERMEDIATE HANDLE927TRANSPORTER 2 ADDRESS: %
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrtnV"e Name Signature
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone N:
<br />Applicable Permit Numbers•
<br />Date
<br />Phone !:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meduml waste as describe) above.
<br />PdnbType Name -. Signature Date
<br />7. DISCREPANCY INDICATION
<br />Transferred containers, cu R to : North Sall Lake, UT
<br />MEDICAL WASTE TRACKING FORM Ni3MBER
<br />Q(f°'� c1e' MI CASE OF EMERGENCY CONTACT. CHEMTREC 1.800.4424-9300
<br />STANDARD MANIFEST 001 -10 -06 -SM
<br />• �etes�tgrmde Mkt: Route #: 123 - 10 CUSTOMER NO. 21132
<br />MDFROM7 91i
<br />1. Generator's Name, Address and Telephone Number {
<br />j
<br />ATTN: t
<br />11111111111
<br />GILL MEDICAL CENTER
<br />(86;q
<br />LE ANNA f Tf X78 7422 (866 783-7422 (866,783-1422
<br />1617 N CALIFORNIA ST
<br />TS/ 36 TS/OST 83 MOST -26
<br />fsTOCIC'I'ON, CA 95209- 6117
<br />t;209j 951-9031
<br />.1211/2015
<br />CUBWMER NUMBER 6111852-001 GENMATOR S REMSMATION #
<br />TREATMi certify that I have)been a orized by the applicable state agency to accept untreated medical wastes and that i have
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />, +
<br />UN3291 Regulated Medical Waste, n.o s.,
<br />T805 - 40 Leal Tub (Bio) (5.3 cu ft)
<br />CONTAINERS
<br />6.2, PGII
<br />s^�
<br />C:Y
<br />Cu Ft
<br />32911 Regulated Medical Waste, n.0 s.,
<br />TB49 - 37 Gal Tub (Bio) (4.9 Cu TV
<br />III.
<br />Cu FL
<br />CC
<br />UN3291 Regulated Medical Waste, n o.s.,
<br />TH14 - 44 Gal Tub(Bio) (5.9 Cu tt)
<br />0-
<br />6.2, PGII
<br />Cu FL
<br />UN3291 Regulated Medical Waste, n o.s.,
<br />- a - -
<br />&2. PGII
<br />Cu FL
<br />W
<br />UN3291 Regulated Medial Waste, n.o s.,
<br />UTB31- (Bio) /WL)31- (Path) /WC31- (Chemo) 31 Gal TUB ( C
<br />}
<br />6,2, PGII
<br />Cu Ft
<br />IZL
<br />Regulated Medical Wtft, nos.,
<br />6
<br />U043- (Bio) /EW42- (Path) /CtkT42- (chemo) Gal Tub (5.7CUFT)
<br />232911
<br />Cu Ft.
<br />Regulated Medical Waste, n.o s.,
<br />KRB - Biosyatees Cardboard Box (4.2 cu ft)
<br />6.23'1!
<br />Cu Ft
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />Cu FL
<br />u Ft
<br />S. Generator's Certification: 11 hereby declare that the contents of this consignment are fully and accurately TOTALS ®
<br />Cu Ft
<br />d ed above by the proper shipping name, and are classified, packaged, marked and iabeged/piacard d, and
<br />are Spects in proper condition for transport according to applicable international and national an u ns."
<br />Jilecl(Weid rQ�
<br />+pt -i
<br />PA Name, Ss tura
<br />at t
<br />�
<br />.T PORTER t�teDRE
<br />r�kycle, Inc. This is rough shipment
<br />hone #: f -
<br />re
<br />9X35 W. Swift Ave
<br />Applicable Permit Numbers -
<br />Bauler Reg# 3400
<br />Fresno,CA 93722
<br />� 0
<br />a
<br />TRANSPORTER RTIFICATIONpt of medical waste as dere ab
<br />Print/lype Name C/ Signature
<br />Date
<br />5. INTERMEDIATE HANDLE927TRANSPORTER 2 ADDRESS: %
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PrtnV"e Name Signature
<br />e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS.
<br />Phone N:
<br />Applicable Permit Numbers•
<br />Date
<br />Phone !:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of meduml waste as describe) above.
<br />PdnbType Name -. Signature Date
<br />7. DISCREPANCY INDICATION
<br />Transferred containers, cu R to : North Sall Lake, UT
<br />fQ 8A Designated FacONiy: 8B. Atmmate FeeilRy: SC. Alternate Facinty ® So. Alternate Fecilny.
<br />cycle, Inc. Stedcycle, Inc. Stericycle, Inc. Staaricycle, Inc.
<br />413E e 90 N. Foxboro Olive 1651 Shelton Drtve 3140 N 7th Streettrry
<br />Fres CAAUTpCt,A , o lit! I alt9, tri' 84(35 Hollister, CA 96023 Kansas City, KS 66116
<br />(86;q
<br />LE ANNA f Tf X78 7422 (866 783-7422 (866,783-1422
<br />TS/ 36 TS/OST 83 MOST -26
<br />EC 0 72 15
<br />TREATMi certify that I have)been a orized by the applicable state agency to accept untreated medical wastes and that i have
<br />received ta�tte�d� wastes in accordance th the requirement outlined m that authorization.
<br />, +
<br />PrinMpe N"-" Signature Date
<br />s^�
<br />C:Y
<br />
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