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V%inr'Medical Waste <br /> rl is Waste, Inc. <br /> 91:09 S.Arrowhead Ave. CA <br /> -)*Tu <br /> San Bernardino,CA 92408 <br /> ra 1 c n t trans anter a TrackEng C <br /> Transporter Permit#5687 ���FO,0` <br /> Transfer Station Permit#123 <br /> L.LPA#CAL000401279 <br /> Generator Information Contact Information <br /> Name: L tifumi i Cve Fp_aJj y Site : (C F 24 HOUR EMERGENCYPHONE. <br /> Address: 77C7 S.Austin Road Telephone 209-467-4657 Support provided by Chemtrec <br /> City: ,— t State: C Zip; Route: w=: 1-800424-9300 <br /> Delivered to customer-Clean containers <br /> U ` 32 1, Regulated Medical aste, n. . ., 6.2., PG 1t <br /> Picked Up From Customer <br /> !i It <br /> Dim <br /> „'i � <br /> Container Qry, Weight Container gty Weight Container Qty, Weight Container City. Weight Container <br /> Ct;y, Weight <br /> 20l <br /> 20 <br /> 2a. <br /> as <br /> 30 38 <br /> 40 <br /> 40 <br /> 44 ae <br /> 95 9s <br /> 3U8-TOTAL. " Stf9-TSFTAI SUB-TOTAL SUtIOTP' SU9.TOTAL. <br /> Notes,comments,or Discrepandes <br /> Signatures For Compliance and Authorizations <br /> b dadatethatttWcontentotthtsconstgnaieOtarehftandaecwatetydwaibedabowbyproper iAw# rdedaremat*SVOW"A-rvatee"M71raarddus marmot Total Contalnem <br /> 000ing item and we dessiried,packed,rnarked and labeled,and are in a#aspatta in pmw cdndhion ces asd by the MC ode ofradent agaraaeaesanWar Total"Qross Weight <br /> fortransponaccoxdkrgtoappkablegoyMrnentreanimtronsand A"aftm0rgofTransportatian. awcea stateaabsand itegalaearu MinusTare Weight: <br /> Total Net Lbs <br /> Customer Name: _ Customer Signature: Date: <br /> Print FU ame) (PI Sign Fu tisej; <br /> Route Driver: -" Route Driver Signature Date: A1 AR <br /> t <br /> Print FULL Name) (P sign FULL ane) <br /> cern of Receipt: ation of receipt of waste as covered by this tracking document number HeaMiwiseServices,4800 E.Lincoln Ave.,Fowler,CA 93625 <br /> Transfer Onver: Transfer Driver Signature: Date: <br /> (Please Print FULL Name) (Please Sign FULL Name] <br /> :ertificate of Receipt: Certification of receipt of waste as covered by this tracking document number. <br /> Superior A4adiiat Ntaste Inc,,2671269 S.Arrowhead Ave.,San Bernardino,CA T:a00-973-4430 TS_123 <br /> Signature: Date: <br /> Cerftcaft of tion:'Cerification of destruction of wasteas covered by this tracking document number, Haaithwise Services;480)E.Lincatn Ave:,Fowler,CA 93625 T:559-834-3333 TS-89 <br /> signature: Date: Transporter Permit#6070 <br /> Wipated Faciitty Ahemste,Designated FacHkY Aftemate Designated Facility Akim-aftDodpated faciihy A#emete DeOPSted fadifty Alternate Designated fadity Alternate Designated Facility Alternate Deagnated facility <br /> vporior Medical waste,Inca Healthwise Service,LLC M entai letmobaos,LLC. <br /> 671269 S;Arrowhead 48M E.Lincoln Ave. 1463 Fayette St. <br /> an 9errwdmo,CA 92408 Fowler,CA 9362,5 V Cajon,CA 92920- <br /> W)973.4430 16593 8344333 (619)448.2406 <br /> eranit#123 Pennit a TS49" Perratit 4TS-.OST45:. <br /> ranspnrtoe Porn+rt:8587 'rartsgonor Permtt:6ti70 " <br />