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uperior MedicaI Waste, Inc. <br />Superior <br />Superior Medical Waste <br />267/269 S. Arrowhead Ave . <br />CA <br />EL -Q/ <br />San Bernardino, CA 92480;UDPICA <br />Trackinb Document <br />(800) 9734430 <br />Permit # 6324 <br />Tracking # <br />Transporter <br />Transfer Station Permit # 123 <br />CDC214 <br />EPA# CAL000401279 <br />Contact Information <br />ienerator Information <br />lame: Site #: <br />CHCF <br />24 HOUR EMERGENCY PHONE: <br />Califoriiia Health Cafe Facility <br />Telephone: <br />209_467_4657 <br />Support provided by Chemtrec <br />tddress: 7707 S. Austin Road <br />:sty: State: Zip: Route: <br />1-800-424-9300 <br />Delivered to Customer -Clean Containers <br />UN3291, Regulated Medical Waste, <br />n.o.s., 6.2, PG 11 <br />11 <br />licked Up From Customer <br />"� p� <br />✓() i <br />1 it <br />Container Qty. Weight Container Qty. Weight Container Qty. Weight <br />Container Qty. Weigh "ComalkneqrQty. Weight <br />20 <br />"� w <br />�) <br />8 <br />28{jt'1 <br />8 <br />38 <br />0 <br />40 <br />4 <br />44 <br />6 <br />96 <br />UB -TOTAL SUB -TOTAL SUBTOTAL <br />SUB -TOTAL 5U8•TOTAL <br />Notes, Comments, or Discrepancies <br />signatures For Compliance and Authorizations ' <br />hereby declare that the contort of Mn consignment are fu8y and accurately descihed above by proper er declare Mu this shipment of waste Is tee of hazardous and mercury Total Containers: <br />tipping name and are clammed, packed, marked and labeled, and are in all aspects In proper condition s as defined by the US rode of Federal Regulate= and/or Total Gross Weight: <br />F'. <br />or transport according to applicable government regulations and Department of Transportation. r appmphte State Rales and Regolatwm. <br />Minus Tare Weight: —11 <br />Total Net Lbs: <br />t , <br />P.�,�Customer <br />' Date: <br />Name: aw3 Customer Signature: <br />(Please Print FULL Name <br />(Please Sign FULL Name) <br />Route Driver: Route Driver Signature: <br />Okos?1 <br />Date: i 16 <br />I V1 <br />(Please Print FULL Name) <br />(Please sign U Na <br />:ertificate of Receipt: Certification of receipt of aste as covered by this tracking document number. <br />He wise Services, 4800 E. Lincoln Ave„ Fowler, CA 93625 <br />Transfer Driver: Transfer Driver Signature: <br />Date: <br />(Please PrInU061.1. Name) <br />(Please Sign FULL Name) <br />:ertifi ate of Receipt: Certifi o i t of waste as covered by this tracking document number. <br />T TS -123 <br />signature: <br />ati. <br />certificate of Destruction: Cerification estruction of wa as covered by this trackin moot number. <br />Healthwise services, 4800 E. Lincoln Ave., Fo 9366 T: 9-834-3333 TS -89 <br />Date: <br />Transporter Permit #6070 <br />signature: <br />)esignated Facility <br />Ll <br />Alternate Designated Facility <br />Alternate Designated Facility <br />Alternate Designated Facility <br />Alternate Designated Facility <br />Altemate Designated Facility <br />Alternate Designated Facility <br />Alternate Designated Facility <br />aperid Medical Waste, Inc. <br />Healthwise Service, LLC <br />National Green Gas, LLC <br />:67/2696. Arrowhead Ave. <br />4800 E. Lincoln Ave.82-579 <br />Fleming Way, Suite F <br />;an Bernardino, CA 92408 <br />Fowler, CA 93625 <br />Indio, CA 92201 <br />800)97? -4430 <br />(559)834-3333 <br />(760)347-4422 <br />'emit # 123 <br />Permit # TS49 <br />Permit # TS--0ST-99 <br />-ransporter Permit: 6324 <br />Tansporter Permit: 6070 <br />