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A 'St del'! .yc e' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-eoaa2a-93oo <br />'•' ek Route #: 123 - 13 CUSTOMER NO. 21132 <br />. Generator's Name, Address and Telephone Number <br />ATTN: <br />GILL MEDICAL CENTER <br />1517 N CALIFORNIA ST <br />STOCKTON,* CA 95204- 6117 <br />MEDICAL WASTE TRACKING FORM NUMBER <br />STANDARD MANIFEST 001-10-08•5TD <br />MDFROOHEVO <br />(209) 451-9031 <br />CusmmrmNumum 6111852-001 GENERATOR'SREammAnot;# <br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE <br />UN3291 Regulated Medical Waste, nos., <br />6 2, P911 TB05 - 40 Gal Tub {Sic}' {5.3 cu ft} <br />6 NS291� Regulated Medical Waste, a a a, TB4 9 - 37 Gal Tub (Bio) (4.9 cu tt) <br />® 6UNN3291 Regulated Medical Waste, n ox, TB14 - 44 Gal Tub (Bio) (5.9 eu ft) <br />PeR <br />Q UN329t Regulated Medical Waste, n os., T821- (8:[O) /TP15- (Path) /TY15- (chemo) 20 Gal Tub (2.7CUFT <br />rr 62, Pell <br />W UN3291 Regulated Medical Waste, n.o a. WB31- (Bio) /WP31- (Path) /WC31- (Chemo) 31 Gal Tub (4.14CUP <br />Z 6.2, PGI) <br />62,,PPGI� Regulated Medical Waste, R o.s., WB43- (Bio) /Pd43- (Path) /Cw43- (Chemo) Gal Tub (5.7CUPT) <br />UN3291 Regulated Medical Waste, n.o.s., KRB - Biosystems Cardboard Box (4.2 cu ft) <br />UN23229C,11� Regulated Medical Waste, n o s., <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TaTALs <br />above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />1n a pacts In proper con44n for transport aowrdeng to applicable international and national go"1lgrnm4ntal regulations <br />(;/%Iprf Name ' <br />PORTER I ADDRESS: <br />Stericycle, Inc. <br />4135 W. Swift Ave <br />M a. Fresno,CA 93722 <br />a <br />TRANSPORTER <br />rKATION: R elpt�off mad(l�ca'l waste as <br />Print/ivne Name 1 /'®Y-� \ Signal, <br />® This i a Through Shipment <br />S. INTERMEDIATE HANDLER 27 TRANSPORTER 2 ADDRESS. �.,..J <br />a <br />gig <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: ReoeIpt of medical waste as described above <br />Print/fype Name Signature <br />1/26/2015 <br />2C. NO. OF 21). VOLUME <br />CONTAINERS <br />a <br />Phone# (1866) 783-7422 <br />Applicable Permit Numbers: <br />Hauler Reg# 3400 <br />Date / /f w <br />Phone M <br />Applicable Permit Numbers: <br />Date <br />�, e. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #. <br />� Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />E5 - PrinVtype !Jame Signature Date <br />in011- ilZUTIN,Tlt.rdCqTNlC%, <br />8A. Designated Facility. CIF❑ 88. Alternate Facllny: E] 8C. Alternate Facility: ❑ 80. Aftemate Faenity: <br />` <br />.tea Steficycle, Inc Stericycle, Inc. Sb9ricycle, Inc. Slaricycle, Inc. <br />to 4136 W. �6 80 N. F oro DrIn 1651 Shelton Drive 3140 N 7th Mettlfy <br />Freano,CA 3722 `Z® North Sal Lake. UT 84054 HDillster, CA 95023 Kansas Cly, KS 66116 <br />(866)783.7422 ` � �6 (866)783.7422 (866)783-7422 (860783-7422 <br />LUTWOST22 ,�'3A-"S-JA-38 TSIOST' 83 TSIOST-26 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />F- received the above Indicated wastes In accordance with the requirement outlined In that authorization. <br />PdnVIWe Name Signature Date <br />TranshtTed containers, Cu R to : With ak Lake, UT <br />Q <br />ORIGINAL <br />i � I <br />