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a•:o Sgericyce' <br />•• <br />° e,0 <br />nftrroat..ee1*• <br />tN CASE OF EMERGENCY CONTACT. CHEMTREC 1.600.424-9300 <br />110-411— off. 10'4 _ 7 G CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001 -1008 -STD <br />NTransferred containers, cu h t0 : North Sak Lake, UT <br />I <br />1. Generator's Name, Address and Telephone Number <br />ATTN: 1111 X11 II <br />IIIIi til III I lid <br />GILL MEDICAL CERM <br />1617 N CALIFORNIA ST <br />STOCKTON, CA 95204— 6117 <br />(209 1-4011 <br />111912016 <br />CUSTOMER NUMBER rail.10 GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 28. CONTAINER TYPE <br />20. NO. OF 2D. VOLUME <br />� 3PGJ1 Regulated Medical Waste, n.os., <br />CONTAINERS <br />-It <br />Gu Ft <br />ON3291 Regulated Medical Waste, n os., <br />6.2, PGII <br />TB49 - 37 Gal Tub Bio 4.9 cu Lt <br />0 Gu Ft <br />X <br />UN3291; Regulated Medical Waste, n o s, <br />�Y <br />p <br />62, PGII <br />TB14 - 44 Gal Tub Bio 5.9 Cu 'Et) <br />Cu Ft. <br />QUN3291 <br />Regulated Medical Waste, mos., <br />62, PGII <br />TB21- (810) /TP15- (Path) /TXa.5- (Chemo)20 tial Tub (2.7C1 <br />CC <br />Cu Ft. <br />UJ <br />UN3291; Regulated Medical Waste, It o s, <br />6.2, PGII <br />W831- (Bio) /W31- (Path) /=I- (Chemo) 31 Gal Tub (4.34 <br />) Cu Ft. <br />iZ <br />UN32291 Regulated Medical Waste, n o.9, <br />6.2, GII <br />- Chemo 1 Tub 5 : CUFT <br />Cu Ft <br />UN3291' Regulated Medical Waste, n.o.s., <br />` <br />6.2, PGII <br />8 cu ft)' <br />Cu Ft. <br />UN3291Regulated Medical Waste, n.o a, <br />62, PGII <br />Cu Ft <br />Cu Fl. <br />3. Generator's Certification: "I hereby dieclare that the contents of this consignment are fully and accurately TOTALS ® <br />Cu FL <br />de ed above by the proper shipping name, and are classified, packaged, marked and labelled ipi ed, and <br />I I respects m proper �n for transport according to applicable International and national ental regulations.* <br />` <br />P ted/typed Name ig <br />CC <br />SPORTER 1 ADDRESS: <br />Phone R. <br />hers: -7 22 <br />St:eriaycle, Ina. This is a Through shipment <br />ApplicableP� It6tNur <br />q <br />4135 W. Swift Ave <br />Hauler Reg# 3400 <br />ur <br />CC <br />F>resao,CA 93722 <br />TRANSPORTERAGERWICAT <br />Receipt o decal waste as descn a <br />% cT+✓ (/ <br />h <br />Pnntfiype Name Signature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSMRTER 2 ADDRESS- <br />Phone #: <br />Applicable Permit Numbers. <br />g <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Re elpt of medical waste as described above <br />PilriMpe Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS <br />Phone #. <br />Applicable Permit Numbers <br />3 <br />z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinVfype Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />Designated Facility: ® 88. Alternate Facility: j] SM Alternate Facility: <br />❑ 81) Alternate Facility: <br />v <br />Stericycte, Inc. Stetscycle, Inc. Sterlcycle, Inc. <br />Sterlcycle, Inc. <br />a <br />80 N. F"Oro Dove 1651 Shelton DrW* <br />VE <br />3140 N 7th Streettry <br />Nath Sett Lake. UT 84064 HolUa;er, CA 96023 <br />Kansas City. KS 6611S <br />(® E ORTIZ� (866)783-736 (868)783.7422 <br />83.22 <br />))7 <br />(866)783-7422 <br />3 SI <br />-26 <br />T EA N't" ILITY: I ceLu rtify that 1 h e been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />cel e,,JJa��b��ove indicated wastes in ac ordance with the requirement outlined In that authorization. <br />P nVrype Nadi@ j <br />Signature <br />Date <br />NTransferred containers, cu h t0 : North Sak Lake, UT <br />I <br />