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Superior Medical Waste, Inc. <br />Superior Medical Waste <br />267/269 S. Arrowhead Ave. <br />CA <br />San Bernardino, CA 92480 <br />1'PERI29 <br />ICA Tracking Document <br />(800) 973-4430 <br />Tracking # <br />Transporter Permit # 6324 <br />Transfer Station Permit # 123 <br />C aC 178 <br />EPA# CAL000401279 <br />venerator information <br />Contact Information <br />Jame: Califonria Health Care Facility Site #: <br />CHIEF <br />24 HOUR EMERGENCY PHONE: <br />tddress: 7707 S Austin Road Telephone: <br />209-467_4657 <br />Support provided by Chemtrec <br />:ity: State: Zip: Route: <br />1-800-424-9300 <br />Delivered to customer - dean containers <br />UN3291, Regulated Medical Waste, <br />nao.s., 6.2, PG II <br />Rcked Customer <br />Up From <br />Container _Qty. Weight Container Qty. Weight Container Qty. Weight <br />Container Qty. Weight <br />Container Qty. Weight <br />20 <br />S <br />28 <br />S <br />38 <br />?AOL I <br />40 <br />l <br />44 <br />96 <br />JB -TOTAL SUB -TOTAL SUB -TOTAL <br />SUB -TOTAL <br />SUB -TOTAL <br />Notes, Comments, or Discrepancies <br />ignatures For Compliance and Authorizations <br />2 <br />Hereby declare that the content of this consignment are fogy and accurately describedabove by proper'buthcrdeclare that this shipment of waste is fee of hanrdoos and mercury Total Containers: <br />ipping name and are classified. packed, marked and labeled, and are in all aspects In proper condition wastes as defined by Um US rade of federal Regulations a Wor Total Gross weight: <br />Iand/or <br />61 <br />ittransport according to applicable government regulations and 0epentment of Transportation. apprapdate State Rules and Regulatims. <br />Minus TareW ight: <br />Total bs: <br />WLC((filtlw7 <br />_ <br />c <br />Ct..,.omer Name: �L� Customer Signature: <br />' (P nt FULL Name) <br />(Please Sign FULL Name) <br />Date: <br />/, <br />Route Driver:Atv�'Route Driver Signature: <br />Date: f <br />(Please Print FULL Name) <br />(Please sign L Name) <br />ertificate of Receipt: Certification of receipt of waste as covered by this tracking document number. <br />He thwise Services, 4800 E. <br />Lincoln Ave., Fowler, CA 9362S <br />Transfer Driver: Transfer Driver Signature: <br />Date: <br />(Please Print FULL Name <br />(Please Sign FULL Name) <br />ertificate of Receipt: Certification of e) of w covered by this tracking document number. <br />� 1 fe <br />Ino y 123 <br />ignature: <br />f <br />a e: <br />:ertiNcate of Destruction: Cerification of destr on of waste as covered b racking docu <br />Healthwise services, <br />4800 E. Lincoln Ave., Fow r, CA 93625 : 559.834-3333 TS 89 <br />ignature: <br />Date: (p�dL/Y Transporter Permitn6o7o <br />esignated Facility <br />Alternate Designated FacBity, <br />Alternate Designated Facility <br />Alternate Designated Fadffty <br />Alternate Designated Facility <br />Alternate Designated Facility <br />Alternate Designated Facility <br />Alternate Designated Facility <br />tperior Medical waste, Inc. <br />Healthwise Service, LLC <br />National Green Gas, LLC <br />;7/269 S. Arrowhead Ave. <br />48W E. Lincoln Ave. <br />82-579 Fleming Way, Suite F <br />in Bernardino, CA 92408 <br />Fowler, CA 93625 <br />Indio, CA 92201 <br />00)973 40439 <br />(559) 8343333 <br />(760) 347-4422 <br />1 <br />=1t# 123 <br />Permit #TS -89 <br />Permit#TS-•OST-99 <br />ansporter Permit: 6324 <br />Tansporter Permit: 0 <br />