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24-Hour Emergency Phone Tracking Document Number: <br /> Number: 888-785-7225 <br /> 14CPQ 1 <br /> - ACT Medical Waste Tracking Document <br /> environmental services <br /> o Facility Name: M9C1kBCS Unified Sfta—I Nstr#ct(Sierra F%%j t Name: Kimberty Wright <br /> ao 17DO Thomas St <br /> 0 Z Address: Phone: <br /> ManteGa, CA 9533.7 Mg-R-58.0gstl <br /> Shipping Descriptions) #of Cont Cont Size Estimated Actual *Treatment <br /> Type Weight Weight <br /> UN 3291,Regulated Medical Waste,N.O.S. <br /> 6.2,PG it <br /> Z UN 3291,Regulated Medical Waste,N.O.S. <br /> 0 6.2,PG 11(Pathological Waste) <br /> � I <br /> a <br /> UN 3291,Regulated Medical Waste,N.O.S. <br /> v. <br /> 6.2,PG 11 (Chemotherapy Waste) <br /> a_ <br /> c0 <br /> Z Non-Hazardous Pharmaceutical Waste <br /> Q. <br /> a <br /> z <br /> H <br /> Non-Regulated <br /> Other(specify): <br /> :4=A utoclave, 1=incineration,M=Microwave <br /> Advanced Chemical Transport, Inc. CA Hazardous Waste Registration:4026 <br /> 1210 Elko Drive,Sunnyvale,CA 94089 EPA ID#:CARD00070540 <br /> IX W e Motor Carrier Permit:0194741 <br /> o a ❑ 1214 Elko Drive ❑ 2010 Mission Ave. 265 Riggs Avenue ❑ 13722 Carmenita Road <br /> w Sunnyvale,CA 94089 Escondido,CA 92029 Merced,CA 95341 Santa Fe Springs,CA 90670 <br /> 408-548-5050 760-489-5600 209-722-4228 714-545-2191 <br /> ~_ MWTS Permit#TS-42 MWTS Permit M-100 MWTS Permit#TS-8 <br /> Print Name: Signature: Dake: l <br /> a Name: DOT#: <br /> Address: State Transporter#of Permit: <br /> 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 /> 0 Q marked and labeled,and are in all respects in proper condition for transport according to applicable governmental regulations. I certify that this shipment does <br /> o a not contain regulated hazardous and or radioactive waste. I am aware that there are significant penalties for submitting false information including the possibility <br /> 9 of fines and imprisonment <br /> W!!: <br /> Z i <br /> Signature. {` ,i _ J` v 1 - Print Name- <br /> / kIlDate:i <br /> ❑ Advanced Chemical Transport ACT Medical ❑ Advanced Chemical Transport Advanced Chemical Transport <br /> 1210 Elko Drive 2010 Mission Ave. 265 Riggs Avenue 13722 Carmenite Road, <br /> w Q Sunnyvale,CA 94089 Escondldo,CA 92029 Merced,CA 95341 pgantpba:5p 90670 <br /> U) 408.548 5050 760-489.561)0 209-722-4228 1-9 Z. ,, °f ° <br /> Z a MWTS Permit#TS-42 Permit#TSIOST-66 MINTS Permit#TS-100 MWTS Permit 0 TS-6 <br /> zy <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 Medic& ❑ Waste Management Healthcare Other <br /> Z 2010 Mission Road Waste Disposal Solutions <br /> O Escondido.CA 92029 4800 E.Lincoln Ave Fowler 4280 Bandini Blvd <br /> 5 760-489-56DO California 93625 Vernon,CA 90058 <br /> i Permit TSIOST-66 559-834-3333 323.31)7.0514 <br /> m a Permit#TS-39 Permit#TS1oST•B1 <br /> w <br /> THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE DESTINATION FACILITY CHECKED ABOVE. Signature&Date: <br />