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02/13/2019 831-13530092 0002169627 <br /> .4sY� ru.Anas6Ennen.r <br /> Medical C C I Document Route No. TR301 <br /> Customer: <br /> LINCOLN POST ACUTE 24-Hour Emergency Response (800)424-9300 <br /> 1032 N Lincoln St <br /> Stockton, CA 95203.2409 Customer Service (855)SOH-0392 <br /> Description of Waste Container Type No.of Ib.or <br /> Containers Volume <br /> UN3291, Regulated Medical Waste, N_O.S., 6.2, PGII 17 GALLON (Regulated Medical Waste(Bio)) 17.000000 gal <br /> UN3291, Regulated Medical Waste, N.O.S-, 6.2, PGII 31 GALLON(Regulated Medical Waste(Bio))31.000000 gal <br /> UN3291, Regulated Medical Waste, N.O.S.,6.2,PGII 43 GALLON(Regulated Medical Waste(Bio))43.000000 gal i <br /> Transporter 1: Totals r <br /> WM Healthcare Solutions,Inc. Applicable Permits: <br /> 1996 Don Lee Place Ste.C Escondido-5688-MW-172 Phone#t_ (760)489-5009 <br /> Escondido,CA 92029 Vernon-5688-MW-157 Phone#: (323)307-0514 <br /> Transporter 1 AcknoWl-edgement.of Rt@Olpt of Materials ; <br /> Signature �.r Print/Typed Name <br /> Date r <br /> Transporter 2: <br /> Permit# Date <br /> Address --' Signature <br /> Printed Name <br /> Autoclave ransfer Facile arisfer Paclli Indneration Facile Incineration Facility Alt Treatment Facilityroc <br /> 42BO Vernon M —..-pessin S ` <br /> WLOW CQvanta Energy HEST Services Aemerge RedPak Healthwlse Services <br /> 4280 Bandlnl Blvd 5251 Trlana Blvd SW 1420 40th Street North Services S-C-,LLC 4800 E.Lincoln Av- <br /> Vemon,CA 90058 1333 E.Turner Rd Huntsville,AL 35805 Fargo,ND 58102 9600 E.Avenue Fowler,CA oln A <br /> Phone(323)S/0ST 84 Lodi,Ca 95240 Phone(256)88T-1019 Phone(701)282-7373 Hesperia CA,92345 Phone(S59)834-3333 <br /> Permit#: TS/OST 81 Permit T/S 34 Permit#:709-1104 Permit#:ITS-0203 Phone(760)983.2808 Permit#:TS-89 <br /> Permit#:TS/0ST 135 <br /> Signature 5ignature Signature Signature Siglqa jM -� <br /> Date va a Date Date Date Date <br /> Iscrepancy Treatment Fac ty Certifica on of Receipt and Destruction <br /> "I certify that the contents of the listed containers)have been received,treated,and <br /> disposed of at one or more of me racilities indicated above In accordance with all local,state, <br /> and federal regulations." <br /> omments <br /> Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are classified,package <br /> marked and labeled/placarded,and are In all respects In proper condition for transport by highway according to applicable international and national government regulations,Including <br /> applicable state regulations." <br /> Signature - Print/Typed Name J Date <br /> 6N/99 'd "N AdSt : � 61R '01 '1dy <br />