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MEDICAL WASTE TRACKING FORM NUMBER
<br />o*.*'.** S t e r I ycle" IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800.424-9300 STANDARD MANIFEST 001 -10 -MSM
<br />"�` Route #., 123 – 12 CUSTOMER NO. 21132 MDFROOHDOO
<br />Generator's Name, Address and Telephone Number
<br />ATTN:
<br />GILL MEDICAL CE
<br />1617 N CALIFORNIA ST
<br />STOCKTON, CA 95204- 6127
<br />091 451-9031
<br />1/12/2016
<br />VOLUME
<br />Cusmmen NumsER6� g 5 .. V O GENERATORS REGIMMAMN #
<br />� j �. � Cu Ft
<br />2A. DESCRIPTION OFWASTE 28. CONTAINERTYPE
<br />2C. NO. OF
<br />UN3291 Regulated Medical Waste, n.os.,
<br />6.2, Pall TB05 – 40 Gal Tub (Bio) (5.3 cu Etc)
<br />CONTAINERS
<br />62,, PGII Regulated Medical Waste, n.o S..
<br />6.2TB49 – 37 Gal Tub (Bio) (4.9 Ca ft)
<br />P ntedrWed Name �- s °' '� ig d
<br />®
<br />2, PG11 Regulated Medical waste, n o.%, TB14 – 44 Gal Tab (Bio) (5.9 Cu. tt)
<br />4. SPORTER 1 ADDRESS:
<br />TR
<br />a6
<br />�) Regulated Medical Waste, n.o s., TB21– (BTO) /TPIS- (Fath) /TYIS– (chemo) 20 Gal Tuts (2.7CUPT
<br />This is a Through Shipment
<br />St:et:icyale, IttG • 9
<br />Applicable PsemuE Numbers•
<br />a
<br />41.35 N. Swift Ave
<br />W
<br />W
<br />UN3291 Regulated Medical Waste, n.o e.,
<br />6.2, P611 - N831-,(Bio)/NP31-(Path)/NC31-(Chemo)31 Gal Tub(4.14CUF
<br />)
<br />62PG11 Regulated Medical Waste, n.o.s.,
<br />2 43– (Bi.o) /PK43– (Path) /CK43– (Chemo) coal Tub (5.7CUFT)
<br />TRANSPORTE_Rr,.ERTIFICATIecelpt of medical waste as describe
<br />UN3291 Regulated Medial Waste, n.o.%,,
<br />6.2, Pall Mw— – Biosystems cardboard Box (4.2 cu ft)
<br />j
<br />1/12/2016
<br />VOLUME
<br />j SA. designated Facility:
<br />Steri cls Inc.
<br />WJE
<br />z (8 RTIZ
<br />� / 2
<br />JAN12 7016
<br />ENT FACILITY: i certify that I
<br />t- ece the, Above ndicat rites In
<br />nntrnvoe Name
<br />s
<br />w
<br />80. Aitemate FaciBty: u 8C. Attemate Favidy: u 8D. Attemate Facility:
<br />Stericycle, Inc. Stericycle, Inc. Stedr1e, Inc.
<br />90 N. Foxboro Drive 1551 Shelton Drive 3140 N 7th Strsettrr►
<br />Notch Salt take, UT 84054 Hollister, CA 95023 Kansas Cityr, KS 66115
<br />(866)783-7422 (866)783-7422 (866)7834422
<br />3A -"S -JA -36 TS/OST 83 TSIOST 26
<br />ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />.cordance with the requirement outlined in that authorization.
<br />Data
<br />Transferred containers, cit ft to : North Sale Lake, UT
<br />3. Gonerator's Certification: °i hereby declare thatdhe contents of this consignment are fully and accurately I TOTALS ®I
<br />� j �. � Cu Ft
<br />described above by the proper shipping name, and are classified, packaged, marked and labelle ftia rded, and
<br />a all respects In proper condition for transport accordinggitooaapplicable mtemattonai and natty arnmentall regulations"
<br />P ntedrWed Name �- s °' '� ig d
<br />✓
<br />x
<br />4. SPORTER 1 ADDRESS:
<br />TR
<br />Phone #: (8G6)763-7422
<br />This is a Through Shipment
<br />St:et:icyale, IttG • 9
<br />Applicable PsemuE Numbers•
<br />a
<br />41.35 N. Swift Ave
<br />HaulerReg1t< 3400
<br />N
<br />Fresno, CA 93722
<br />a
<br />TRANSPORTE_Rr,.ERTIFICATIecelpt of medical waste as describe
<br />f-
<br />j
<br />PnnVrW& Nama Si$nattue
<br />Date "r
<br />5. INTERMEDIATE DL 2 /TRANSPORTER 2 ADDRESS-
<br />Phone #.
<br />lie
<br />Applicable Permit Numbers:
<br />v+
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medroai waste as described above.
<br />PrinMpe Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #
<br />Applicable Permit Numbers:
<br />INTERMEIIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />PdnUtype Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />j SA. designated Facility:
<br />Steri cls Inc.
<br />WJE
<br />z (8 RTIZ
<br />� / 2
<br />JAN12 7016
<br />ENT FACILITY: i certify that I
<br />t- ece the, Above ndicat rites In
<br />nntrnvoe Name
<br />s
<br />w
<br />80. Aitemate FaciBty: u 8C. Attemate Favidy: u 8D. Attemate Facility:
<br />Stericycle, Inc. Stericycle, Inc. Stedr1e, Inc.
<br />90 N. Foxboro Drive 1551 Shelton Drive 3140 N 7th Strsettrr►
<br />Notch Salt take, UT 84054 Hollister, CA 95023 Kansas Cityr, KS 66115
<br />(866)783-7422 (866)783-7422 (866)7834422
<br />3A -"S -JA -36 TS/OST 83 TSIOST 26
<br />ave been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />.cordance with the requirement outlined in that authorization.
<br />Data
<br />Transferred containers, cit ft to : North Sale Lake, UT
<br />
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