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Addilk <br />law <br />. MEDICAL WASTE TRACKING FORM NUMBER <br />O® ®O '�Qj^'cyCle° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.4249300 STANDARD MANIFEST o01.105r0 <br />h°ta" . fl s➢A6k CUSTOMER NO. 21132 mnERQDHMK <br />1. Generator's Name, Address and Telephone Number <br />ATTN: IIII I I II ll 1 1111111111011111 it 111111 <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />ST==N, CA 95204- 6117 <br />209 451-9031 12/29/2016 <br />, <br />CusvoMERNutasn 6111852-001 GENERASORsREG1sTRAT1oN$ <br />2A. DESCRIPTION 01; WASTE 28. CONTAINERTYPE 2C. NO. OF 2D. VOLUME <br />UN3291 Regulated Medical Waste, rtios., CONTAINERS <br />6.2, PGI> T1305 - 40 Sal Tub (Bio) (5.3 cu ft) Cu Ft. <br />B 2 PG13 291 Regtdated Medical Waste, n.o s., TB49 - 37 Gal Tub (Bio) (4.9 Cu ft) Cu Ft <br />®UN3291 <br />23Pall Regulated Medical Waste, n.o.s., TB14 - 44 Gal Tub (Hi o) (5.9 Cu ft) Cr, Ft <br />Q 6NS291i Regulated Medical Waste. n.o.s., T221- (B=O) /TP1S- (Path) /TY15- (Chemo) 20 teal Tub (2.7Cu>P ) <br />CC Cu Ft <br />W UN3291 <br />23PGi� Regulated Mad Waste, nos, <br />WB31— (Bio) /NP31— (path) /WC31— (Chemo) 31 Gal Tub (4.14C ) Cu Ft <br />62, PG1� 3291 Regulated Medical Waste n os , mB43_ (Bio) /PW43— (Path) /CW43— (Chemo) Gal Tub (5.7CUPT) Cu FL <br />662.PPGII Regulated Medical Waste, n.os., nB_ — — Biosystems Cardboard Box (4.2 au ft) Cu Ft. <br />UN3291, Regulated Medical Waste, n os.. <br />r� <br />GF <br />3. Gene tor's Certification: 11 hereby declare that the contents of this c onsTgnment are fully and acc tiratety I TOTALS � <br />I I (_ Cu FL <br />above by the proper shipping name, and are classified, packaged, marked and labelled/placardW, and <br />Aar <br />�= <br />In all s In prop�filerrlor mnsport according to applicable International and na7en 1 regulabons° <br />T <br />1 Pff ed Name !A4 s ria " <br />v Da <br />4. IRAN ORTER 1 ADDRESS: <br />Phone #. (666) 783-7422 <br />SteriCycle, Inc. This is a Through shipment <br />Applicable Permit Numbers: <br />4135 W. Swift Ave <br />HaulerReg# 34Q0 <br />ai <br />a <br />resno,CA 93722 <br />TRANSPORTS CIE N: Re dkal vWts as descnb <br />Prtn a Nameai=—Ignature <br />Date <br />.. <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone ri <br />a <br />Applicable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Printffype Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone # <br />Applicable Pen M Numbers - <br />xINTERMEDIATE <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />Prinu ype Name Signature <br />Date <br />7. DISCREPANCY INDICATIO1 <br />9a <br />} " <br />i— <br />8A. Designated Faculty: es. Alternate Facility: 8C. Alternate Facility: <br />®81). Alternate Facility. <br />ftiid"G. Inc. 5tsdcycle, Inc. Stedcycle, Inc. <br />Steftcycle, Inc. <br />F <br />4135 W. S It Ave 90 N. FuOom Wn 1551 Shemon Dove <br />3140 N 7th 8"Gliiay <br />FPesno,CA 93722 North Set Latae, UT 84054 Hollister, CA 95023 <br />Kansas Cly66975 <br />(866)7834422 (866)783-7422 (866)783-7422 <br />,KS <br />(866)783-7422 <br />Uj <br />T3/OST22 8A -40 -.Mill T3108T 83 <br />TSIOST-26 <br />f <br />T FITMENT FAA 1UEdy that I ha been authorized by the applicable state agency to accept untreated medical Wastes and that i have <br />re Ived the)ACE8ANLtqj&„es In a been <br />With the requirement outlined In that authorization. <br />IPri <br />veype Name Signature <br />Dcig <br />Ttant:fe Ted containers, cU R to : North Sale Lake, UT <br />17 <br />r� <br />