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. MEDICAL WASTE TRACKING FORM NUMB <br />Steric C®e® STANDARD MANIFEST 001.10./6 -STD <br />de' -.De i7 IN CASE OF EMERGENCY CONTACTt CHEMTREC 1-BOtM24.8300 <br />•rr.0 r"i. Route #: 123 - 18 CUSTOMER NO. 21132 MDFRO;EH8 DE <br />1. Generator's Name, Address and Telephone Number <br />ATTN: <br />GIZL MEDICAL CEN UR <br />1617 N CALIFORNIA ST <br />sTocmzi, CA 95204- 6117 <br />(209) 451-9031 <br />1.2/8/2018 <br />U. Designated Faci t . ® 88. ANemate Facittty. <br />V'* <br />Inc.Stericycle.Inc. <br />TGCLAV Xboro Drive <br />7 <br />North reit Luke. 11'f 84054 <br />-7 ANNIE Q TIZ (866'7 3-7422 <br />DEC 08 201 <br />TREATMLed;6ove <br />CILITY, I certify that I h+ <br />Mcetved IndicategL waste In ai <br />Pnntiype <br />8C. Aftemate Faeluty: <br />Stericycie. Inc. <br />1551 Shelton Drive <br />Hollister, CA 96023 <br />(866)783-7422 <br />T'SIGST 83 <br />81). ANernate Fatpsty: <br />Sterlcycle, Inc. <br />3140 N 7th Street3rtj+ <br />Kansas CRY. K5 66115 <br />(8661783-7422 <br />TSIOST 26 <br />authorized by the applicable state agency to accept untreated medical wastes and that I have <br />a with the requirement outlined in that authorization. <br />Date <br />CusromunNu►mien 6111852-001 GENanArowsRsct,sTRAnoN <br />2A. DESCRIPTION OF WASTE <br />28• CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UUNNS291 Regulated Medical Waste, n os., <br />, P13311 <br />TB05 - 40 Gal Tub (Bio) (5.3 cu tt) <br />CONTAINERS <br />Cu F <br />6N329116 Regulated Medial Waste, n o s., <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />Cu F <br />® <br />'i Regulated Medica! Waste, n os., <br />TB14 - 44 Gal Tub (Bio) (5.9 Cu Y.t) <br />6U <br />Cu F <br />Q <br />UN3291, Regulated Medical Waste, nos., <br />TS21- (BIO TF1 d Path TY - C emo Ga <br />M <br />6.2, PG11 <br />Cu Ft <br />W <br />UN3291 Regular Nledlcel Waste, n o s., <br />WB31- (Bio) /WP31- (Path) /NC31- (Chemo) 31 Gal Tub (4.140 <br />) <br />Z <br />6.2, PGII <br />Cu Ft <br />tu <br />Regulated Medica! Waste, no s„ <br />W943- (Bio) /PW43- (Path) /Cet43- (Chemo) Gal. Tub (S.7CUFT) <br />623PaII <br />_ Cu Ft. <br />UN3291 Regulated Nhdical Waste, n.o s., <br />Biosystems Cardboard Box (4.2 cu ft) <br />6.2, PGIl <br />— <br />Cu EL <br />UN3291 RegulatedMedical Waste, n.os, <br />6.2, Poli <br />Cu Ft. <br />a <br />Ft ' <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® <br />= Cu It, <br />dasc above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />n a respects In proper condition transport according to applies Intemational and nail Mirgental regulations" <br />AL IA I <br />r� <br />P ntedrilyped Name .••P^" 111A AffW—gnat <br />� <br />4. SPORTER 1 ADDRESS: <br />Stericycle, Inc. This i a T ough Shipment <br />Phone I <br />4135 A. Swift Ave <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />�_ N <br />Fresno,CA 93722 <br />4 <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as describe ove <br />Print/Type Name `� Signature <br />Date _ <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS- <br />Phone 8 <br />n <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br />PdnViype Name Signature <br />Date <br />B. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #. <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above <br />PdnVlype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />I <br />Transferred containers, t W R to : North oak Lake, UT <br />L. <br />U. Designated Faci t . ® 88. ANemate Facittty. <br />V'* <br />Inc.Stericycle.Inc. <br />TGCLAV Xboro Drive <br />7 <br />North reit Luke. 11'f 84054 <br />-7 ANNIE Q TIZ (866'7 3-7422 <br />DEC 08 201 <br />TREATMLed;6ove <br />CILITY, I certify that I h+ <br />Mcetved IndicategL waste In ai <br />Pnntiype <br />8C. Aftemate Faeluty: <br />Stericycie. Inc. <br />1551 Shelton Drive <br />Hollister, CA 96023 <br />(866)783-7422 <br />T'SIGST 83 <br />81). ANernate Fatpsty: <br />Sterlcycle, Inc. <br />3140 N 7th Street3rtj+ <br />Kansas CRY. K5 66115 <br />(8661783-7422 <br />TSIOST 26 <br />authorized by the applicable state agency to accept untreated medical wastes and that I have <br />a with the requirement outlined in that authorization. <br />Date <br />