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O ®O S R.erwcycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-tioa-424-93aO <br />• vmea iuoq. neid,k Route #-. 123 - 18 CUSTOMER NO. 21132 <br />MEDICAL WASTE TRACKING FORM NUMBER I <br />STANDARD MANIFEST 001 -10.06 -STD <br />MDFROOHFUM (a <br />01VLOHF-11 <br />1. Generator's Name, Address and Telephone Number <br />AIM; <br />GILL MEDICAL CENTER <br />1617 N CALILPORNIA ST <br />sTocKMNI CA 95204— 6117 <br />(209) 451-9031 2/2/2016 <br />Cuvmm nNuureER 6111852-001 GENERATorrsREGISTRAnoN# <br />2A. DESCRIPTION OF WASTE 213. CONTAINERTYPE 20. NO. OF <br />CONTAINERS6.2, <br />20. VOLUME <br />UN3291 Regulated Medtai Waste, n.os., <br />PHTBQ5 - 40 t3ai Tub {Bio? (5.3 cut <br />Cu Ft. <br />UN3291 Regulated Medial Waste, n.o.s., TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br />6.2, P611 <br />Cu Ft. <br />® <br />623299 Regulated Medial Waste, n.o.s., TB14 - 44 Gay Tub (Bio) (5.9 cu tt:) <br />6.2, PGdI <br />t Cu FL <br />UN3M1I Regulated Medial Waste, n as., TB21- (B=Q) /TP15- (Path) /TrLS- (chemo) 20 Gal Tub (2.7cun <br />Cu Ft. <br />W <br />623291 Regulated Medical Waste, 11-m.UF (Bio) /wp31- (Path) /WC31- (Chemo) 33. tial Tub (4.14CtTF ) <br />6 2, PGII <br />Cu Ft <br />IZ <br />6.23PolI Regulated Medical Waste, n.os., WB43- (Bio) /PW43- (Path) /CW43- (Chemo) tial Tub (5.7CUPT) <br />Cu FL <br />6.23299 Regulated Medial Waste, n as., BitCardboard Box (4.2 cu ft) <br />6.2, PGII XRB --Biosystems <br />Cu Ft. <br />UN32911I Regulated Medical Waste, rl.o s., <br />Cu FL <br />99 B <br />3: Gne tore Certification: °! hereby declare that the contents of the consignment are fully and acxuratet TOTALS ® Cu Ft. <br />above by the proper shipping name, and are classified, packaged, marked and labelledtplacard nd <br />lr,kd.x,l respects In proper condition for transport according to ap Ircabte international and natio auons' <br />r v <br />P tsdrlyped Nam 19 it, <br />IX �u <br />:T PORTER 1 ADDRESS: one #: (066) 783-7422 <br />Stericycler Inc. This is a T on9h Bitrzpment Applicable Permit Numbers: <br />® <br />4135 W. Swift: Ave Battler Reg# 3400 <br />D0 <br />E'reeno, CA 93722 <br />a Z <br />TRANSPORTER iIFICATIOM, of medical waste as desratb a <br />Printl ype Name Signature Date Z-�4 <br />INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />cti <br />l�� <br />Applicable Permit Numbers <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/9ype Name Signature Date <br />6. INTERMEDIATE HANDLER 3 !TRANSPORTER 3 ADDRESS- Phone #. <br />Applicable Permit Numbers: ! <br />1 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PnnVrype Name Signature Dais <br />7. DISCREPANCY INDICATION <br />eA. Designated Faalitty: 0 se. A femme Facility: ® SC. Attemate Facility: BD. Altemate Faetgty: <br />Q <br />3larlaycle, Inc. ® Startcyr:[e. Inc. Ste rt yr Inc. SWrlcycle. Ino. <br />4135 .. Sib 90 N. Foxboro Drive 1551 Shelton Dhve 3140 N 7th Stmetti}y <br />Freeno,CA 722North Set Lalm, LIT 84054 Hollister, CA 85023 Kenses Cly, KS 66116 <br />(866)783-7422 {866)?8&7422 <br />(868)783-7422 ®�, (86SM13-7422 <br />2 3A-448,6436 TSIOST 83 TS/OST-26 <br />ja <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have I <br />received the above Indicated wastes In accordance with the requirement outlined In that authorization. <br />pdnMp,o Name Signature Date <br />Transferred iners, CU R b : Norlh Salt lake, UT <br />rn <br />01VLOHF-11 <br />