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s <br />®.16 7ter'cyclea <br />^-- – -- — -- MEDICAL WASTE TRACKING FORM NUMBER <br />WA s M <br />u at tCY OffACP CHEMTREC 1.604424-9304 STANDARD MANIFEST 001 -10 -06 -SM <br />CUSTOMER NO. 21132 MDFROOH9AM <br />1. Generator's Name Address and Telephone Number <br />WWN <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOCKTON, CA 95204- 6117 <br />III 11111111111111111111111111111101,111111111111111111,111 1 <br />(209) 451-9031 <br />CUSTOMER NUMBER 6111852-001 GENERATOR%REGisTRAT10N# <br />2A. DESCRIPTION OF WASTE 2B. CONTAINERTYPE <br />6 3291 Regulated Medical Waste, nos , THOS – AO Gal. Tub (Bio) (5.3 cu ft) <br />UN3291 Regulated Medical Waste, n.o s., Tub 4 (4.9 Cu <br />6.2, PGII <br />pG 1IN3291 R.maintaA Marlir.21 Waafa n n a 4 Cu t <br />Qp 62, PGIl <br />W 6NM <br />.2PGi� <br />W UN3291 <br />Z 6 2, PGII <br />Lu <br />0lIiV32911 <br />nos <br />Regulated Medical Waste, n o s.,I <br />Regulated Medical Waste, n o s., <br />3. Generator's Certification: "I herebydecia�e that the contents of this consignment are fully and a <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/pl <br />ap4aAraspects In proper condition for transport according to applicable international and national <br />kMBOISPORTER 1 fQW2ievyCle, 1nC. Ej This is a <br />4135 V. Swift Ave <br />® FraanorCA 93722 <br />-W <br />a TRANSPORTER RTIFICATI celpt of medical waste as des <br />c <br />I F– Printffte Name r ( Slonature <br />31 Gal <br />Gal Tub(S.7CLikT) <br />2 cu ft) <br />xxrotra ly TOTALS 1► <br />and <br />g nmental regulations? <br />hrough shipment <br />12/15/2015 <br />2C. NO. OF 21). VOLUME <br />CONTAINERS <br />Phoned <br />Ap� IjP r 'Vu, 400 <br />d000r <br />Date 1 0- <br />S. INTERMEDIATE HANCLER 21/TRANSPORTER 2 ADDRESS: Ptuxne d: <br />rn Appiwable Permit Numbers <br />6�e INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as dembed above. <br />Priv a Name Signature Date <br />EYP I9 <br />i, % 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone d. <br />i� Applicable Permit Numbers <br />a a INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as desmbed above. <br />7. DISCREPANCY INDICATION Transferred containers, cu ft to : North Sabt Lake, UT <br />Facility. <br />i. Inc. <br />� <br />Is t.-1 '1111NE ORTIZ <br />a ^ DEC 15 2015 <br />lu <br />Pig TR ATt1AET FACILITY: I certify that I <br />re IV0146' a ve In Gated stees In <br />11 <br />013. <br />es. Alternate Focally. <br />Ststicycte, Inc. <br />90 N. Foro Drive <br />Tgrth Sal Lake, UT 84064 <br />BC. Alternate Facility: <br />Sterlcycle. Inc. <br />1661 Shelton Drive <br />Hollister, CA 95023 <br />(866)783-7422 <br />TS/OST 83 <br />BD. Altemate Facinty: <br />SWrlcyale, Inc. <br />3140 N 7th Milittllyr <br />Kansas CBv, KS 56116 <br />(886)783.7422 <br />TSIOST=26 <br />been authorized by the applicable state agency to accept untreated medical Wastes and that I have <br />'dance With the requirement outlined in that authorization. <br />Vnig7rSaY/{6. <br />Date <br />