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Superior Medical Waste, Inc. <br />iPE O_T)E <br />Superior Medical Waste <br />267/269 S. Arrowhead Ave. <br />CA <br />4EDiCAL WASSan <br />Tracking Document <br />Bernardino, CA 92480 <br />(800) 973-4430 <br />Transporter Permit # 6324 <br />Tracking # <br />GC Flo 0 <br />Transfer Station Permit # 123 <br />EPA# CAL000401279 <br />generator Information ` /R 4 ict •� <br />( <br />Contact Information <br />Cp(�jQ'i�j�i /( <br />Site #: G''� C <br />24 HOUR EMERGENCY <br />;ame: <br />i�" �iiCj n j/('� <br />PHONE: <br />ddress: t� <br />Telephone. <br />:ity: !j �ijZ"� <br />Support provided byChemtrec <br />Stater Zip: Route: <br />1-800-424-9300 <br />y <br />UN3291, Regulated Medical Waste, n.o.s., 6.2, PG II <br />Delivered to customer -Clean containers <br />1-cled From <br />Up Customer <br />1 <br />Container Qty. Weight Container Qty. Weight Container Qty- Weight Container qty. We$ht ".!l Qty. W t <br />t <br />20 <br />t <br />28 <br />t <br />38 <br />D 40 <br />44 <br />96 <br />IB -TOTAL SUB -TOTAL SUB -TOTAL SUB -TOTAL I I I SUB -TOTAL <br />Notes, Comments, or Discrepancies <br />ignatures For Compliance and Authorizations <br />a, meby declare that the content of this consignment are fully and accurately described above by proper irunher declare nut mis shpment ofwaste h fee ofheia,dot. and mercury Total Containers:_ <br />pping name and are classified, packed, marked and labeled, and are in all aspects in proper condition wastes as dented Iry the us code of federal eeguladoos andlor Total Gross Weight: <br />r transport according to applicable government regulations and Department of Transp nation. amllor approprWte State auks and Regulations. Minus T eWeight: 0 <br />T Net Lbs: -- ' <br />r <br />r <br />n <br />Cun,Jmer Name: Customer Signature: t"t/ Date: <br />( ease Print F L ame) (Plea SignZ <br />Route Driver: _ _ Route Driver Signature: Date: <br />(Please Print FULL Name) (Please nFULLName) <br />J <br />,rtificate of Receipt: Certification of receipt of waste as covered by this tracking document number. eaithwise Services, 4800 E. Lincoln Ave., Fowler, CA 93625 <br />Transfer Driver: Transfer Driver Signature: Date: <br />(Please Print FULL Name) (Please Sign FULL Name) <br />rtificate of Receipt: C rtificati of rece' waste as covered by this tracking document number. �te n r n S-123 <br />;nature: a e! /ham /� <br />3rtifiwte of Destruction: Cerification of destr n of waste as covered by this tracking document number. Healthwise services, 4800 E. Lincoln Ave., q CA 93625 559.834-3333 7S-89 <br />;nature: <br />Date:A21 ZG I♦(� Transporter Permit 46070 <br />signaled Facility Alternate Designated Facility Alternate Designated Fadlity Alternate Designated facility Alternate Designated Facility Alternate Designated Facility Alternate Designated Facility r Alternate Designated Facility <br />eriorMtedical Waste, Inc. Healthwise5ervice, LLC National Green Gas, LLC <br />/269 S. Arrowhead Ave. 4800 E. Lincoln Ave. 82-579 Fleming Way, Suite F <br />Bernardino, rA 92408 Fowler, CA 93625 Indio, CA 92201 <br />)) 973.4430 _ (559) a34-3333 (760) 347.4422 <br />A <br />nit #'223 Permit 8 TS -89 Permit R TS -OST -99 <br />isporter Permit: 6324 Tansporter Permit: 6070 <br />