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Superior Medical Waste <br />-'� Superior Medical Waste, Inc. 267/269 S. Arrowhead Ave. CA <br />VIEDICALRj San Bernardino, CA 92480 <br />Tracking Document (800)973-4430 Traddng# <br />Transporter Permit # 6324 G� <br />Transfer Station Permit # 123 <br />EPA# CAL000401279 <br />Generator Inform on j if % rQ �„/G f j a� y �^ h.^ Contact Information <br />Name: (1A �f ��� (�/y(/�` 'f "' Site �l / `/ `�.- - 24 HOUR EAAERGENCYPHONE: <br />Address: 1--W.�j- i ' -Al r oLd Telephone: `"�� / Support provided by Chemtrec <br />City State; Zip: "` Route: 1-800-424-9300 <br />oolkn rad to auromer-Own C.ntalnen <br />• _ked Up From Customer <br />0 <br />UN3291, Regulated Medical Waste, mo.s., 6.2. PG 11 <br />Signatures For Compliance and Authorizations t <br />Ihaebr dadereUrat the (omen" ottha eordlpmentare tuAyand sowrateiydowfJaBd above byproper IfuMmdedmedutthb4rganmtofwete bk.diavanlmuad mnaoy Total Containers:1 <br />ftPbgraaeard am doollacl, pada4 narked and labeled. and are In all aspegs In prowconfton trasms add byf6eUSCode of redmal R.VbbmamVm Total Gross Weight: <br />fubemport acmrs3ng to appoamble eouawd reaullameaad DepaWmnt or7ranyarb lm and%m gwoyriataaammita&W Reodgin . Minus Tare Weight: <br />Total Net Lbs: <br />9�u <br />Customer Name: 91'A(' 01"111"6yAl Customer Signature: Date: <br />Print FULL Name) (Worse Slgn FULL Name) r ` <br />Route Driver: ute Driver Signature: Date: 6 <br />(Please Print FULL Na., (FLV Nmna) <br />Cert)flwte of Receipt: Certification of receipt of waste as covered by this tracking document number. Healthwfse Services, 4800 E. U.I. Ave., Fowler, CA 93625 <br />Transfer Driver. Transfer Driver Signature: Date: <br />CartRicde of Receipt: <br />Signature, <br />Cerdficate of Destruction: <br />Signature: <br />print <br />of waste as covered by this traciting document number. <br />of waste as covered by this traddrlg document number. <br />FULL <br />earanent4m0herep ndes <br />'t TS -123 <br />*t ate:'t'i,� <br />HoaldwAseSeMom4800EUnodnAwe, Fowler, CA93625T:5S%4B4-3333 Ts -89 <br />Date: <br />Datlilrobd F*WtV <br />Afterne0e DmlgrMW Facility <br />Alternate DesiBfnted FacgRy <br />Akanpte tladvoW Fadifty <br />Aharna0e Dmynated Fad ty <br />Aitwrtate Dated Fadgty <br />Mwrwta DadlinaOsd Fadgtp <br />Alternate Deslsnated Facility <br />superior Medial Wast, hr. <br />Haddra be service, Ut <br />National Green Ga4 LLC <br />267tAS S. Arrowhead AW <br />48M E Uncotn Ave. <br />52-679 FWvft Way, WW F <br />San SaMadlnq CA 92408 <br />Fowler. CA 93623 <br />h k. CA 92201 <br />(800) 9734430 <br />(`159) 834-3313 <br />A <br />(7601347-"22 <br />ParmRS 123 <br />permRSTs-89 <br />Permh4TS-W-99 <br />Tramporter Permlk 6324 <br />Tansporw Famfe <br />