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PRIMA Toll Free: (855) 684-9487 <br /> 12401 Woodruff Ave., Ste. 10 _ Office: (562)246-1250 <br /> Downey, CA 90241 Fax: (562) 478-4580 <br /> Transporter Registration No.: 6106 <br /> Transfer Station Registration No.: TS-5 WASTE MANAGEMENT <br /> EPA 1D No.: CAL000389496 Reducing Waste,Risk and Cost <br /> TRACKING N0: <br /> MEDICAL WASTE TRACKING FORM 11616-R <br /> Emergency Telephone Number.(855)684-9487 <br /> Generator Information: This information is to certify that the materials described below are properly classified,packaged, <br /> E m p Res/ New Hope Post Acute marked and labeled and are in proper condition for transportation in accordance with the applicable <br /> regulations of the United States Department of Transportation. <br /> Care <br /> W2586 Buthmann Avenue <br /> WTracy, CA 95376 NAME OF COMPANY REPRESENTARW(Pnnt) <br /> SIGN41UREOFREPRESENTATIVE DATE <br /> Truck ID: <br /> Regulated Medical Waste,n.o.s.,CLASS 6.2,UN 3291,PG.II #of Volume Estimated <br /> Containers Weight <br /> 96 Gal.(Bio) 44 Gal(Bio) 38 GaL(Blo) 20 tial.(Bio) 10 Gal.(Bb) <br /> 1:1 (128 Cu R) El (5.9 Cuu h) 0 (5.1 cu R) ❑ (27 cu t) ❑ (1 A cut) 2 Cu.Ft. Lbs. <br /> ❑ 44 Gal.(Path) 20 Gal.(Path) 44 Gal.(Chemo) 20 Gal(Chemo) <br /> (5.9Cu1) ❑ (2.7cuit) ❑ (5.9CufQ ❑ (2.7cutt) Cu.R. Lbs, <br /> Pharmaceutical Waste: <br /> Other: Cu.R. Lbs. <br /> Comments: <br /> Replacement Tracking <br /> TOTAL: 2 Cu.R. Lbs. <br /> ❑ ❑ OTHER. ❑ OTHER: <br /> oc ,Ju10 <br /> ti PRIMA NAMEOFCOMPANYRE RESENTATIVE(Prino <br /> 0 12401 Woodruff Ave.#10 Q <br /> 2 Downey,CA 92201 SIGNATURE OFREPRESENTARVE <br /> Tel.(562)246-1250 3124/14 <br /> Transporter Reg if:6106 <br /> DATE OF TRANSPORTATION <br /> Z ❑ x❑ ❑ OTHER: <br /> o � <br /> Q <br /> PRIMA National Green Gas,LLCA )fC MPAN PRES,TATIVE(N (Print) <br /> e s 12401 Woodruff Ave.#10 16457Ave.241,2 <br /> C Downey,CA 92201 Chowchilla,CA 93610 SIGNATURE OF REPRESENTATIVE <br /> ti Tela(562)246-1250 Tel.-(562)246-1250 3/24/14 <br /> TS-5 TTS-7 DATE RECEIVED IN TRANSPORT <br /> ❑ ❑ ❑ OTHER. CERTIFICATION OF DESTRUCTION <br /> 82-579 Fleming Way Ste.F 4280 Bandinf Blvd. The signature below certifies that the above documented waste <br /> Indio,CA 92201 Vernon,CA 90058 was received,treated and disposed of In accordance with all Local, <br /> State and federal Regulations and following all conditions within <br /> V <br /> OST-95 OST-81 our permit,on dates documented. <br /> (562)246-1250 (562)246-1250 <br /> ti <br /> W <br /> g <br /> NAME OFCOMPANV REPRESENTATIVE(Print) <br /> SIGNATURE Of REPRESENTATIVE <br /> DATERECEIVED DATE OF TREATMENT <br /> White-Transporter Yellow-Treatment Facility Green-Transfer Station Pink-Generator <br />