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Q•Q SterwcydW <br />® rMe a°p ft*9 p®dga" O <br />MEDICAL WASTE TRACKING FORM NUMBER <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.800-424-9300 STANDARD MANIFEST 001.10A&STD <br />Route #: 123 — 16 CUSTOMER NO. 21132 <br />1. Gerierator's Name, Address and Telephone Number <br />ATTR: <br />GILL MEDICAL CENTER <br />1617 N CALI]PORNIA ST <br />STOCKTON, CA 95204- 6117 <br />CusToMeR NUMBER Al 1 R! <br />2A. DESCRIPTION OF WASTE 26. <br />6UN322911i Regulated Medical Waste, n o 4., <br />UN3291 Regulated Medical Waste, n.0.4.1 <br />62, PGII <br />CC O 6UN3291 Regulated Medical Waste,11.c s.2, P611, <br />Q UN3291 Regulated Medical Waste, 11.0.4., <br />62, PGI <br />W UN3291 Regulated Medical Wade, n 0.4., <br />tZ 6.2. PGII <br />6N PGII Regulated Medical Waste, 11.0 L. <br />UN3291 Regulated Medical Waste, n.0 a., <br />6.2, PGII <br />UN3291 Regulated Medical Waste, n.0.4., <br />6 2. PWI <br />451-9031 <br />GENERATOR'S REGISTRATION # <br />CONTAINER TYPE <br />TB05 - 40 tial Tub (Bio) (5.3 Cu ft) <br />TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) <br />TB14 - 44 Gal Tub(Bio) (5°9 Cu ft) <br />1821-(BTG)/TP15-(math)/Tri5-(Chemo)20 Gal Tub(2. <br />WB31-(Bio)/WP31--(Path)/WC31-(Chemo)31 Gal Tub(4.14CU <br />61843- (Bio) /PW43- (Path) /cu343- (Chemo) Gal Tub (5.7CUFT) <br />KRB -� Biosystems Cardboard Box (4.2 cu ft) <br />3. Generator's CertiflcaUon: "1 hereby declare that the contents of this consignment are fully and accurately TOTALS <br />described above by the proper shipping name, and are classified, padtaged, marked and labelled1placarded, and <br />are in all respects in proper condlti r transport according to applicable international and " <br />fnd national governmental regulations <br />Printedtryped Name S�®r Signature <br />4. TRANSPORTER 1 ADDRESS, <br />Sterieyele, Inc. ® This is a Thro h 8hi ant <br />tCd 4335 N. Swift Ave <br />Fresno,CA 93722 <br />ME <br />a TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinUryps Name +' + Signature <br />6. INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: <br />rye p <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Recelpt of medical waste as described above. <br />PrinNrype Name Signature <br />IC. NO.OF <br />CONTAINERS <br />22/2015 <br />VOLUME <br />Cu FI <br />+°� Cu Ft <br />Date G <br />Phone#• (066)783-7,12; <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date i <br />Phone #. <br />Applicable Permit Numbers. <br />Date <br />6. INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone N. <br />g Applicable Permit Numbers. <br />RINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />E PrinVWe Name Signature Date <br />INDICATION <br />,I / Transferred containers, ou R to : North Sail Lake, UT <br />8A. Designated FacBRy: <br />813. Alternate Faollfty: <br />❑ 8C. ARemate Facility: <br />[] 80. Alternate Facility: <br />ie. irtt:. <br />SterlGyCie, Inc. <br />Stellcycle, Inc. <br />41 5W.SMAWTOCLAVxti <br />ro Drive <br />1661 Shelton Drive <br />3140 N 7th Streettdy <br />no,CA tM ANNE ®alt <br />Lake, UT 84054 <br />Hollister, CA 915023 <br />Ifansas CityICS 66115 <br />(a <br />)783-7 22 <br />7422 <br />(866)783-7422 <br />(S66i783-7422 <br />T=2 <br />DEC 2� 20 <br />D <br />JA -36 <br />TSIOST 83 <br />TSIOST-26 <br />EATME <br />FILITY: I certify that <br />thonzed by the applicable state agency to accept untreated medical wastes and that I have <br />rived th <br />above to t dartsIth <br />the requirement outlined to that authorization. <br />Date <br />IE <br />4 <br />