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ATTACHMENT C Troddrog Doam Beet Number. <br /> ACT 0107W 03,'04!2016 <br /> Advanced Chemical Transport <br /> Medical Waste Tracking Document <br /> GENERATOR INFORMATION <br /> Manteca U.S. . tp. ) KL'nAXTN wt'�t <br /> Facility Name: Contact Name: <br /> Address: 647 W Lath"Rd tip'CA 95330 � Phone; 1209)828-0&10 <br /> S H I P P I N G I N F 0 R M A T 10 N fA= Auroclove, 1=lntinem on, M-Micrawove) <br /> Shipping Description(s) Number of Container Estimate Actual Trew- <br /> _ Containers Type Weight J1161-6j" Mesa <br /> Regulated Medical Waste 6,2,UN 3291,PG II <br /> • Regulated Medical Waste 6.2,UN 3291,PG II(Pathological Waste) P P 1"CM <br /> i <br /> Regulated Medical Waste 6.2,UN 3291,PG II(Chemotherapy Wastel <br /> Non-Regulated or Expired Pharmaceuticals <br /> Other(specify)_ <br /> ' Transporter.Advanced Chemical Transport, Inc. <br /> }� California Hazardous Waste Registration 4026 <br /> ❑' 1210 Elko Drive ❑ 2213 Meyers Avenue <br /> Sunnyvale,CA 94089 Escondido, Cd 92029 <br /> Phone(408)548-51150 Phone(760) 489.56DO <br /> MWTS Per#TS-42 MWTS Perla TS-64 Signature d Date <br /> Nome: Secondary Transporter: <br /> Address: _ <br /> Phone s gnaloe&Dole <br /> Generator's Certification: <br /> This is to certify Thal the materials described above ore properly classified,packaged,marked and labeled and are in proper condition for transportation in ouordonce <br /> with the applicable regulations of the United States <br /> Department of Transportation and the State of California. <br /> Signature&Date 24-hour Emergency Phone# <br /> (Tr=Treatment, Ts=Transfer) Destination Facility: <br /> ❑ Staricyde,loc. ❑ Chambers County Resorrco ❑ Sareltec USA <br /> ❑ Soaiter USA ❑ Siericycie,Inc. <br /> Tr/Ts Station Recovery sod Racycliy Facility Tr/Ts Facility Ts Station Tr/Ts Station <br /> 1345 Doolittle Drive,Suite{ Tr/Ts Statins 9065 Martis Avenue 1900 Apron Avenue 01260 2775 Easi 261h Slreel <br /> Sao teandra,(A 94511 7501 State Highway 65 Sun Volley,(A 91352 Atwater,(A 95301 Vernon.(A 90023 <br /> 15101636-1502 Anahuac,T%17514 (8181504.0343 (2091368.0205 131313623000 <br /> AtWTS Per#19-23-P (886)611-0103 MWTS Pero 1S/OST 20 MWTS/tr#TS-45 MWTS Pert p-1 15 <br /> �J1WTF Per o'❑j� p p Mrrair#4111(hiSW#2239A f��ithu�'jSC ,�('?Y'L•r;�g THIS i5 TO CERTIFY THAT THE WASTE IDENTIFIED <br /> 0lwr ABOVE WAS RECEIVED AT THE DESTINATION FACILITY <br /> CHECKED ABOVE. <br /> Signorure&'Dore <br />