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Ingeniurn " t <br /> 2255 Barham Drive Ste.A ■ t <br /> Escondido,CA 92429 = <br /> Ph;800-8050-6236 P r ' <br /> Fax-760-745-8786 % a , <br /> MEDICAL WASTI.E., DOCUMENT <br /> Generator 1 Address Contact/24 Hour Emergency.Phone <br /> AMS icill FIM,ka_ <br /> Transporter 1: Transfer Station: (if Applicable) <br /> Ingenium Group-LLC <br /> 40v4 APW'" <br /> 2255 Barham Drive,Escondido,CA'92029j� <br /> DTSC Hazardous Waste Transporter Regis n#4857 wc <br /> 600-805-6236 k i <br /> Designated Disposal/Tr fer Facility: (check One) <br /> [I Medical Waste H Wise ❑ oftr ❑ Othw. ❑ Ottler <br /> Services 4800 E Lincoln A <br /> 7321 Quimby ST Fowler,Cry 93625 <br /> Paramount,CA 90723 855-248-9473 <br /> 888-610-1311 Pwnit# <br /> Permit#:TSl0ST94 <br /> Shipping Information: (Treatment Code.i=Incineration,M=Microwave;A-Aut ve <br /> f Description Court Cont Type . Est, WL Treatment New Tracking to <br /> ransfer Facility) <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG 11(ERG#158) ,.r ] <br /> LIN 3291,Regulated Medical Waste,62, <br /> PG If(Pattological Waste RG#158 <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG It Chemothera Waste ERG#158 <br /> Pte. <br /> PharmaceuticalWaste r <br /> k This is to certify that the matenais descri ve` mperly dassffled, packaged, labeled and are in <br /> proper condition for trans ation in a applicable regulations of the United States Department of <br /> Transportation and the State of ilio <br /> Generator: <br /> Mame:(Print) S' Ujre: <br /> Date- <br /> In accordance with CA ' 040-Tracking Records,generator transporting medical waste shall maintain ifs copy of the <br /> shipping'gW tracking documents forth years <br /> . . <br /> Transporter 1: <br /> Name:(Print) Signature Date: <br /> Tr er do iicable <br /> (Print); Signature: Date. <br /> Trans er 2: ifApplicable) <br /> Name:(pnw signature: Date: <br /> Designated Disposal/Transfer Facility <br /> Name:(Print)' , S` Date- <br />