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MEDICAL. WASTE TRACKING FORM NUMBER <br />Stericytle' IN SUF�O�P EJNER Y cON�A - CHEWREC 1-610-024.9300 aTANt?AR[I�ldttVV <br />r woes,• Arc jcv diff CUSTOMER NO. 21132 ii'Rl lUJLL'' FKC <br />1. Generator's Name, Address and Telephone Number <br />ATTN! <br />GILL MEDICAL CENTER <br />1617 H CALIFORNIA ST <br />STOC3(''TON, CA 95204- 61.17 <br />(209) 451-9031 <br />CUROMER NUMBER 6111852-001 GENERATOWSREC,I MAnON0 <br />2A. DESCRIPTION OF WASTE 213• CONTAINER TYPE 2C. NO. OF <br />6 2322991 Regulated Medical Waste, nos., TBO5 — AO Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br />UN3291, Regulated Medical Waste, n o s„ — <br />6.2, PGII <br />CC p B 2II Regulated Medical Waftn O.S.. — <br />UN3291 Regulated Medial Waste, rr.o.s., <br />CC 6.2, PG16 <br />111 ON Regulated Medical Waste, n.o.s., <br />12 62, Pail <br />a UN3291 Regulated Medical Waste, n o.S., Tet843— 4� o) X43— (�'a CM — e ease A <br />6.2, PGi� <br />UN3291, Regulated Medical Waste, n.o.s.. m — H osystems cardbo—ard OX <br />3. Canerator's Certification: W hereby declare that the contents of this consignment are fully and accurately TOTALS 00, <br />d�crtbed above by the proper shipping name, and are classified, packaged, marked and tab®fied/placarded, and <br />®may <br />)88 <br />spects In proper condition for transport according to applicable international and na ' ^ emm/en`ttaal�regt5e <br />dal ..e_... LAa 6�f+ !l //1 <br />SPORTER t ADSterlowle, Inc. ® This is a Thr <br />a 4135 V. Swift Ave <br />Nrrteisna, CA 93722 <br />EL TRANSPORTER CERTIFICATION: eeccel�ptroff.(medical wasteasdewrlb <br />Pnnt/TvaeName —! 1[`ra// ) Alnnnh,ra <br />2/16/2016 <br />m <br />Shipment Phone <br />g. ft ez. 3400 <br />N 5.'INTERMEDIATE H-MDLER 2 / TRANSPORTER 2 ADDRESS' <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />PnnMpe Name Signature <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />N SJV9 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above <br />I� <br />PnnttFypa Name Signature <br />I r 1♦-1.-sv =r AfVG:r miuium ruiv <br />Date <br />Phone A: <br />Applicable Permit Numbers. <br />Date <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />vlsns <br />ated Faellity: <br />ricycle, Inc. <br />86. Atternale Facility: <br />Stericycle, Inc. <br />8G. Alternate Faenigr: <br />Steri+ le, int:. <br />8D. A Fac bty <br />�0,Inc. <br />6 W. SwlttA !WNd: <br />90 N. Foxboro Dtive <br />15S] Sh Di�ue <br />8140 7th s�aettrry <br />Isne,CA <br />93722 <br />North Set Lake, L.IT 84064 <br />Hollister, CA 85023 <br />Kansas City, KS 6811E <br />6)783.7422 <br />16 <br />{888)783-7422 <br />(866)783-7422 <br />(868)783-7422 <br />2 <br />rTREATMENT <br />16 3A-448%WSS <br />TSIOST 83 <br />TSIOST 26 <br />(OST22 <br />fE <br />FACILITY: i certify <br />have been authorized by the applicable <br />state agency to accept untreated medical wastes and that I have <br />above indicated wastes In accordance with the requirement outlined in that authorization. <br />e _ <br />Signature <br />nn,e <br />vlsns <br />