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® T MEDICAL WASTE TRACKING FORM NUMBER <br />0® ®QterIC�%d IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.600-4244=0 STANDARD MANIFEST 001•iao&srD <br />' ataia�e Route #: 123 - 111 CUSTOMER NO. 21132 MDFROOHC20 <br />Tranatermt! contalnem, OUR 10 : NOnn Stilt Lalfe, U1 <br />t=, <br />c <br />1. Generator's Name, Address and Telephone Number <br />ATTN.* ! 1111 1 <br />GILL MEDICAL CENTER <br />1617 N CALIFORNIA ST <br />STOI=oN, CA 95204- 6117 <br />(209) 451-9031 <br />1./512015 <br />CusioMERNuroaER 61.11852-001 GENERAsoasREeiaminoti# <br />2A. DESCRIPTION OF WASTE 213. CONTAINER TYPE <br />2C. NO. OF 213. VOLUME <br />UN3291, Regulated Medical Waste, n.ox, TBOS - 40 dal Tub {Baa} {5.3 au ft) <br />CONTAINERS <br />6.2, PGII <br />Cu Ft <br />UN3291Regulated Medial Waste, n.0.s., TB49 - 37 Gal Tub (Bi*) (4.9 Ou ft) <br />6.2, PGII <br />Cu Ft. <br />® <br />UNS291 Regulated Medical Waste, n.o.s., T814 - 44 gal Tub (Bio) (5.9 cu Lt) <br />6.2, PGII <br />Cu Ft. <br />4 <br />UN3291 Regulated Medial Waste„ n.as., T521- (BIO) TP.15�- (Path) TYiS- (Chemo) 20 Gal Tub (2.7CUF <br />) <br />cc <br />6.2, PGI I <br />Cu R. <br />UJ6 <br />Regulated Medical Waste, n.os., UB31- (Bio) /wp3l- (Path) /WC31- (Chemo) 31 Gal Tub (4.149 <br />) <br />2 PGII <br />Cu Ft. <br />Uj <br />Regulated Medial Waste, n.os., ws43- (Bio) /pw43- (path) /CK43- (Chemo) Gal Tub (5.7CUFT) <br />6UN3229911I <br />Cu Ft <br />6.2. 29 I Regulated Medial waste, fus., mB _ Biosystems Cardboard Box (4.2 cu ft) <br />Cu Ft. <br />UN3291 Regulated Medial Waste, n,o.s., <br />6.2, PGII <br />Cu Ft <br />/n LAA� <br />CuI R <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTAI.Cu <br />Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelledtptacarde ,and <br />a i respects tit proper condition for transport according to applicable international and nation/a�leve mental regula s' <br />ra 3 <br />Pr tednWed Name nitiure <br />t — <br />W <br />PORTER 1 ADDRESS:Phone <br />Steri.GyC1e, Inc. This is a Through pment <br />t - <br />® <br />41.35 W. Swift Ave <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />a <br />Fresno,CA 93722 <br />WQ a <br />TRANSPORTER -GE FICATi : R%eceipt of medical waste as deco d <br />f <br />~ <br />Pdnt/lype Name Signature <br />/ — '91 <br />Date a <br />S. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: <br />Phone # <br />"icable Permit Numbers. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Pdnt/rype Name Signature <br />Date <br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone # <br />Applicable Permit Numbers <br />02 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinViype Name Slgnsture <br />Date <br />7. DISCREPANCY INDICATION <br />"L <br />® SA. Designated Facility: ® 813. Altemate Facility: 8C. Altemate Facrnty: <br />® 8D Altemate Faofl[W. <br />Inc. <br />-� <br />Stadcycle, Inc. Sledcycle. Inc. Stericycie, Inc. <br />Drive <br />St:edcycle, <br />8140 N 71h <br />a <br />4136 W. SWIR AVe so N. Femoro Drive 1551 Shelton <br />St estbly <br />U6. <br />Froano,CA 12272b Naft Galt Lake. LM 04064 Hatilabsr, GA 126028 <br />Kansas CILy, Kt3 66118 <br />(666)783-7422 (865)783-7422 (8M763.7422 <br />(866)763-7422 <br />Uj <br />TS/O 2 3A -448 -JA -39 TWOST 83 <br />TS/OST 26 <br />w TREATMENT FAGlLITY: i certify that !have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />the indicated <br />received above wastes In accordance with the requirement outlined In that authorization. <br />PdnVrype Nam® Signature <br />Date <br />Tranatermt! contalnem, OUR 10 : NOnn Stilt Lalfe, U1 <br />t=, <br />c <br />