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• Afterior Medical Waste <br /> r i, rMedical ' 1W1269 S.Arrowhead Ave. CA <br /> MffL�R�� . San Brnardino,CA 92408 <br /> racking (8th})973-4430 Tracking# <br /> Transporter Permit:#6687 <br /> Transfer Station Permit#123 <br /> EPA#CAL000401279 <br /> Generator information Contact Information <br /> Name: �' lrvrt;j1t k'-are Facifity Site#: C-40 <br /> 24 HOUR EMERGENCY PHONE: <br /> Address: 771D7 S. Austin Road Telephone: 2 0 _:n ..- Support provided by Chemtrec <br /> Cityi, 20rkton State: LA ZIP: — <br /> c Route. R,,ieior 2 1-800-424-9300 <br /> Oethwed to Customer Clean container <br /> 3291, Regulated Medical Waste, n. .s., 6.2, PG Ii <br /> Picked Up From Customer <br /> ':(". � ' 'Fi•-d+5:• 4 r 'F4. � .:f7s � L' kk ``�� STF, h r ;.,5s�., d„•. ...' .k N.. <br /> E .lea{.•' <br /> Container Qty. Weight container Qty. Weight Container Qty. weight Container City. Weight Container My, Weight <br /> 20. 20 <br /> 28 28 <br /> 38 38 <br /> 4e 40- <br /> 44 44 <br /> 95 96'. <br /> SUB-TOTAL I SUB-TOTAL -5U6-TOTAL. SUBTOTAL SUB-TOTAL <br /> Notes,CA) nts,orDiscregandes <br /> Signatures Por Compliance and Authorizations <br /> l herabydeclarcthst are cantanYoftRk car meM are fulW aced described above by;raper - Ifunhae dadare thdtns4g shipment ofwasteisfreeof hater rs and mercury Total Containers: <br /> shippins name and are classified,pecked,marked and labeled,and are in all aspacts in prapercartlitlon wastes as dear�d'6y the US Code of Federal Rei taftns and/or Total Gross Weight: <br /> fortranspari according to applicable povemment regulations and Department arTraa+spwtatian. and)ora State Hulas and RedulatloM Minus Tare Weight:.. <br /> Total Net Lbs: <br /> Customer Name: _ Customer Signature: Date: <br /> (Pie ase 'nt fULL Nam (Please 5i FUL -e) Ail <br /> W <br /> Route Driver: Route Driver Signature: Date: <br /> If (Please l t Fu' Name) #Pleas e LL Name) <br /> Centficate of Recialpt Certification of receipt of waste as covered by this tracking document number, ealthwise Services,48M E.Uncoln Ave.,Fowler,CA 93625 <br /> Transfer Driver: Transfer Driver Signature: 10 Date: <br /> (Please Print FULL Name), (Please Sign FULL Name), <br /> certificate of Receipt: Certification of receipt of waste as covered by this tracking document number, Superior Medical waste,Inc,267/269 s,Arrow1head Ave.,son allmardino,CA'r:8W-973-4430 TS-123 <br /> Signature. Date:. <br /> Certificate of Destruction:Cerification of destruction of waste as covered by this tracking document number. Healthwise services,48M E.Lincoln Am,Fowler,CA 93625 T:559-434.3333 Ts-89 <br /> Signature: mate: Transporter Permit#6070 <br /> Dibillignated Fadlity Alternate Designated Facility Alternate Designated lFaclaty Alternate Designated Facility Alternate Designated Fal icy Alternate Designated Facility Atternate Designated Fadiity Alternate Designated Facility <br /> Superior Medical Waste,Inc. Hoakhwise Service,LX meciicallEr rWomerdaiT ies,LLC <br /> 267/269 S.Arrowhead Ave. 4800 E.Lincoln Ave, 1463 Fayette St, <br /> SonSetnerdinq,CA 92408 Fowler,CA 93625 EI Cajon,LA 92020. <br /> (805)973-4430 (559)834.3333 (619)448.2000 <br /> Permit 4123 Permit It TS-89 Permit B TS--OST-BS. <br /> Transporter Permit:.W7 Tansporter Permit:6070 <br />