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" ge'lor Medical Waste <br /> uperior MedicalWaste, Inc. 1269 S.Arrowhead Ave. CA <br /> " San Bernardino;CA 92408 <br /> racking Document (800)973-4430 <br /> Transporter Permit#6687 Tracking ;R2 16 5 <br /> Transfer Station Permit f#123 <br /> EPA#CAL000401279 <br /> Generator information Contact Information <br /> Name., r' rrti4 Health Ca ', Gift Site#: ** 24 FLOUR EMERGENCY PHONE: <br /> Address: 7:007 S.Atisfir, a Telephone:t? 09-46-7-4f-,57 Support provided by Chem#nee <br /> City: f State: ,..,, 7i p: r Route: Rgginp. 7 1-800-424-9300 <br /> _.... ... Deihrered to customer-Clean containers <br /> UN3291, Regulated Medical Waste, naoas., 6.2, PG 11 <br /> Picked Up From Customer <br /> tNMI <br /> r .. L 12a NMI <br /> RContainer Qty. Weight Container Qby Weight Container: qty._ Weight Container Qty. Weight Container Qty Weight <br /> 20 -20 <br /> 28 28 <br /> 38 <br /> 38 <br /> 0 40 <br /> .44 44. <br /> 96 96 <br /> SUBdOTA1 S, T." SUO-TOTAL SUS-TOTAL.. SUa 74TAL <br /> Notes,Comments,or Discrepancies <br /> Signatures For Compliance and Authorizations <br /> I hereby declare that the content of this consignment are fiaiy and accura#(y describod above by proper Ifurtherdadare that this shirmem of waste d tree of hazardous and memny Total Contalners: <br /> shipping name and are classiied,parked,marked and labeled,and are in all aspects in proper condition �as defined bydta US Cod.ef Federal flepla0m and)or Total Grass Weight: .... <br /> for trans according to applfeab[egcaarnmaat regulations ami3Oapanmant of Transportation. and/or approWl t.State Mdas and eeguiafion& Minus Tare Weight;. <br /> Total Net Lbs: 1"k <br /> Customer Name,. Customer Signature Date.- <br /> { ease Print FULL tete) FUL na) <br /> Route Driver:. iff, Route Driver Signature: Date-4(4/1 <br /> //Villt <br /> Ase Print FULL Name) se Sign FULL Name) <br /> Certifi to Receipt: Certification of receipt of waste as covered by this tracking document number: Heaithwise Services,48M E.Lincoln Ave.,Fowler,CA 93625 <br /> Transfer Driver: Transfer Driver Signature: 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.,2671269 S.Arrowhead Ave.,San Bernardino,CA T:800-9734430 TS-123 <br /> Signature: Date: <br /> Certificate of Destruction:Cerification of destruction of waste as covered by this tracking;document number. weakhwise services,4800 E Lincoln Ave.,fowler,CA 93625 T:SS9-834-2333 Ts-89 <br /> Signature: Date: Transporter Permit#6070 <br /> Designated Facility Alternate Designated facility Alternate Designated FadHty Alternate Designated Facifty Alternate Designated Facility Alternate Designated Facility Alternate Designated Facility Alternate Desknated Fatality <br /> superior Medical Waste,Inc Healthwise Service,LLC Medical EnvVonmentaETedi LIC <br /> 26712695.Arrowhead Ave_ 4800 E.Lincoln Ave. 1463 Fayette St. <br /> San Semardlno,CA 92408 Fowler,CA 93625 EI Cajon,CA 92020 <br /> 1600)973.4430 (559)834-3333 (619)44a-2000 <br /> Pert#123 Permit g TS-89 Permit li TS—OST-85 <br /> rranspater Peimk:658? Tansponer Permkr X70 <br />