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24-Hour Emergency Phone TrackirliglDdoufnent Number: <br /> Number: 888-785-7225 iii rot's <br /> ACT` Medical Waste Tracking Document <br /> environmental services <br /> o s f=acility Nam Manteca Lhff ed School Dist ct Perna t Name: K'�°�Wngfrt <br /> �1 NO Thomas St <br /> WX <br /> Zo <br /> Address: Manteca, CA 95337 Phone: 20945MBSO <br /> Shipping Description(s) #of Cant Cont. Size Estimated Actual 'Treatment <br /> Type Weight Weight <br /> UN 3291,Regulated Medical Waste,N.O.S. K. <br /> 6.2,PG II t <br /> UN 3291, Regulated Medical Waste, N.0.5. <br /> 4 3 � r� <br /> 6.2,PG II(Pathological Waste) `� <br /> a <br /> UN 3291, Regulated Medical Waste, N.O.S. <br /> ° 6.2,PG II (Chemotherapy Waste) <br /> 0 <br /> Z_ <br /> 0 <br /> Z Non-Hazardous Pharmaceutical Waste <br /> d <br /> x <br /> to <br /> Non-Regulated <br /> Other(specify): -7 <br /> 'A=Autoclave, I=Incineration,M=Microwave <br /> Advanced Chemical Transport,Inc. CA Hazardous Waste Registration:4026 <br /> 1210 Elko Drive,Sunnyvale,CA 94089 EPA ID#:CAR000070540 <br /> W o Motor Carrier Permit:0194741 <br /> i= 1210 Eiko Drive ❑ 2010 Mission Ave. ❑ 265 Riggs Avenue © 13722 Carmenita Road <br /> QSunnyvale,CA 94089 Escondido,CA 92029 Merced,CA 95341 Santa Fe Springs,CA 90670 <br /> CK 1 <br /> z° 408-548-5050 760-489-5600 209-722-4228 714-545-2191 <br /> baa <br /> ~— MWTS Permit#TS-42 MWTS. Pe " TS-100 QTS Permit#TS-8 <br /> Print Name: V�� r •ern 004'LSignature: Date: i <br /> Name: DOT#: <br /> 00 <br /> Oz Address: State Transporter# or Permit: <br /> N Print Name: Signature: Date: <br /> Z I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified•packaged• <br /> marked and labeled,and are in all respects in proper condition for transport according to applicable governmental regulations. I car*that this shipment does <br /> g 4C not contain regulated hazardous and or radioactive waste. I am aware that there are significant penalties for submitting false information including the possibility <br /> 2 of fines and imprisonment. <br /> W 166 <br /> Zr- <br /> cc <br /> Signature: l 1 Print Name: t, , �Dater �'�'I SCJ <br /> ❑ Advanced Chemical Transport ❑ ACT Medical Advanced Chemical Transport E�- 7rartsport <br /> 1210 Elko Drive 2010 Mission Ave. 265 Rklgs Avenue ikjj�, <br /> O Sunnyvale,CA 94089 Escondido,CA 92029 Merced,CA 95341 Santa Fe Spdngs,CA 9057D <br /> H 408-54&5050 760-089-5600 209-7224228 714-5452191 <br /> F MWTS Permit#TS-42 Permit#TSlOST-66 MWfS Permit#TS-100 MWTS Pamtil Al TS-8 <br /> on <br /> THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE TRANSFER FACILITY CHECKED ABOVE. Signature&Date: <br /> ❑ ACT Medical ❑ Healthwise Services Medical ❑ Waste Management Healthcare ❑ Other <br /> z 2010 Mission Road Waste Disposal Solutions <br /> Q Escondido,CA 92029 4800 E.Lincoln Ave fowler 4260 Banding Blvd <br /> 760-489.5600 Califortna 93625 Vemon.CA 90058 <br /> CJi Permit#TSIOST-66 559-834-3333 323.307-0514 <br /> H LL Permit#TS-39 Permit N TSIOST-8i <br /> W <br /> THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE DESTINATION FACILITY CHECKED ABOVE- Signature&Date: <br />