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MEDICAL WASTE TRACKING FORM NUMBER
<br />O ®Q 5#eriC�/C[@° IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-8300 STANDARD MANIFEW 001-10�-STD
<br />► " . 4! r Route #: 123 - 12 CUSTOMER No. 21132 MDFROOHI OX
<br />1. Generator's Name, Address and Telephone Number
<br />ATTN t
<br />GILL MEDICAL CENTER
<br />1617 N CALIFOR11A ST
<br />STOCXMNj CA 95204- 6117
<br />CuBTOMlm NumeER
<br />UN3291, Reaulated Medial Waste, n.o s
<br />811SI�IIOI�AIIIN�9I��IIBY)9) 461-9031 2/23/2016
<br />01Nl
<br />GENMATon's REGIsMMON #
<br />805 - 40 tial Tub (rdo) _ (5.3 _cu it)
<br />TB49 - 37 Leal Tub (Bio) (4.9 cu tt)
<br />7014 - 44 Gal Tub(Bic) (3.9 out 1:t)
<br />TB21-(BZ®)/T815-(path)/TY15-(Chemo)20 Gal Tub(2.
<br />V831- (Bio) /tibii?31- (Path) /WC31- (Chemo) 31 Gal Tub (4 .
<br />ox, rui' KRB— — Blosystems Cardboat.^ri Box f9.:d Cu
<br />UNS201 Regulated Medical Waste, n.0 s ,
<br />6.2, PG1�
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2. PGIl
<br />3. Geherator's Certification: "I hereby decare that the conterlis of this wnsignment are fully and ccuratety
<br />abava by the proper shlppktg ntlme, and are caesdred, packaged, marked and rdad, and
<br />respects In proper co pion for transport accordkng ►o appllk�bte (ntemationai and aG ve �
<br />nledf'fyped Name ria re °'
<br />a
<br />2C. NO. OF
<br />CONTAINERS
<br />l
<br />VOLUME
<br />Cu
<br />4.TMSPORTER 1 ADDRESS: Phone # cc (866)783-7422
<br />Stericyale, Inc. This in a Through shipment Applicable Permit Numbers:
<br />a 4135 W. Swift Ave Aaulec Reg# 3400
<br />x N Freanv,CA 93722
<br />a Z TRANSPORTS RTIFICA : Receipt of medical waste as d a
<br />Pnnt/type Name Signature Date 1=2 L
<br />S. INTERMEDIATE HANDLE 2 / TRANSPORTER 2 ADDRESS: Phone #
<br />Applicable Permit Numbers-
<br />Rm
<br />N INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PdnVtype Name Signature Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone 0
<br />1 M Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— PrinMoe Name Sionature Date -- 1
<br />ice
<br />a
<br />Z
<br />W
<br />F—,
<br />8A. Designated Facuay. Ot °
<br />C �l
<br />,--°Sb dcycie.Inc. k '",�
<br />4186 W, AY41
<br />Preenc,CA 93722 1
<br />(866)783-7422
<br />T91OSM
<br />Altemate Feallity:
<br />daycle, Inc.
<br />N. Foftilo CM*
<br />North Salt Lake, UT 0400
<br />(866)783-7422
<br />3A -448 -JA -36
<br />8C. Altemate Facaity:
<br />S'ierlccyycle, Inc.
<br />1651 shown Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />80 Alternate Faculty:
<br />Stericycllee. Inc.
<br />31417 N 71h Sftdt*
<br />Kansas City, K$ 66115
<br />(866)783-7422
<br />TSIOST 26
<br />TREATMENT FACILITY: I certify that I have been authonzed by the applicable state agency to accept untreated medical Wastes and that I have
<br />received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />PrInVType Name Signature Date
<br />Transferred containers,ai tt to , North Sat Lake, UT
<br />2A. DESCRIPTION OF WASTE
<br />26UNMI Regulated Medial Waste, n.o s
<br />PGII
<br />UN3291 Regulated Medial Wasia, n.o s
<br />8.2, PGI
<br />pC
<br />0
<br />UN3291 Regulated Medical Waste, n.o s
<br />, 9.2, Pall
<br />Q
<br />UN3291 Regulated Medical Waste, n o s
<br />V. PGI
<br />W
<br />W
<br />UN3291 Regulated Medical Waste, n.o s
<br />6.2. PI)
<br />G
<br />W
<br />Wr
<br />6UN23229G11i Reculated Medical Waste, n.o s.
<br />UN3291, Reaulated Medial Waste, n.o s
<br />811SI�IIOI�AIIIN�9I��IIBY)9) 461-9031 2/23/2016
<br />01Nl
<br />GENMATon's REGIsMMON #
<br />805 - 40 tial Tub (rdo) _ (5.3 _cu it)
<br />TB49 - 37 Leal Tub (Bio) (4.9 cu tt)
<br />7014 - 44 Gal Tub(Bic) (3.9 out 1:t)
<br />TB21-(BZ®)/T815-(path)/TY15-(Chemo)20 Gal Tub(2.
<br />V831- (Bio) /tibii?31- (Path) /WC31- (Chemo) 31 Gal Tub (4 .
<br />ox, rui' KRB— — Blosystems Cardboat.^ri Box f9.:d Cu
<br />UNS201 Regulated Medical Waste, n.0 s ,
<br />6.2, PG1�
<br />UN3291 Regulated Medical Waste, n.o.s.,
<br />6.2. PGIl
<br />3. Geherator's Certification: "I hereby decare that the conterlis of this wnsignment are fully and ccuratety
<br />abava by the proper shlppktg ntlme, and are caesdred, packaged, marked and rdad, and
<br />respects In proper co pion for transport accordkng ►o appllk�bte (ntemationai and aG ve �
<br />nledf'fyped Name ria re °'
<br />a
<br />2C. NO. OF
<br />CONTAINERS
<br />l
<br />VOLUME
<br />Cu
<br />4.TMSPORTER 1 ADDRESS: Phone # cc (866)783-7422
<br />Stericyale, Inc. This in a Through shipment Applicable Permit Numbers:
<br />a 4135 W. Swift Ave Aaulec Reg# 3400
<br />x N Freanv,CA 93722
<br />a Z TRANSPORTS RTIFICA : Receipt of medical waste as d a
<br />Pnnt/type Name Signature Date 1=2 L
<br />S. INTERMEDIATE HANDLE 2 / TRANSPORTER 2 ADDRESS: Phone #
<br />Applicable Permit Numbers-
<br />Rm
<br />N INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />PdnVtype Name Signature Date
<br />S. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS. Phone 0
<br />1 M Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above
<br />— PrinMoe Name Sionature Date -- 1
<br />ice
<br />a
<br />Z
<br />W
<br />F—,
<br />8A. Designated Facuay. Ot °
<br />C �l
<br />,--°Sb dcycie.Inc. k '",�
<br />4186 W, AY41
<br />Preenc,CA 93722 1
<br />(866)783-7422
<br />T91OSM
<br />Altemate Feallity:
<br />daycle, Inc.
<br />N. Foftilo CM*
<br />North Salt Lake, UT 0400
<br />(866)783-7422
<br />3A -448 -JA -36
<br />8C. Altemate Facaity:
<br />S'ierlccyycle, Inc.
<br />1651 shown Drive
<br />Hollister, CA 95023
<br />(866)783-7422
<br />TS/OST 83
<br />80 Alternate Faculty:
<br />Stericycllee. Inc.
<br />31417 N 71h Sftdt*
<br />Kansas City, K$ 66115
<br />(866)783-7422
<br />TSIOST 26
<br />TREATMENT FACILITY: I certify that I have been authonzed by the applicable state agency to accept untreated medical Wastes and that I have
<br />received the above indicated wastes In accordance with the requirement outlined in that authorization.
<br />PrInVType Name Signature Date
<br />Transferred containers,ai tt to , North Sat Lake, UT
<br />
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