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4 24-Hour Emergency Phone Tracking Document Number: <br /> a ,+ <br /> 0;0'W Number: 888-785-7225 <br /> D1857k3 <br /> = Ii <br /> . ACT% Medical Waste Tracking Document <br /> environmental services <br /> 62 Facility Name: Manteca Ur�i1ledSchool DiCtict(East C° 0Lali f: Kimbetly1Rb'1gift <br /> W C 1700 N Lhon Road <br /> Zo <br /> LU <br /> Address: Manteca, CA 95337 Phone: 20"25-0860 <br /> Shipping Description(s) #of Cont. Cont. Size Estimated Actual *Treatment <br /> Type Weight Weight <br /> UN 3291,Regulated Medical Waste,N.O.S. <br /> 6.2, PIS It <br /> UN 3291, Regulated Medical Waste, N.O.S. { 3 C1 C[ } <br /> Z 6.2,PG it(Pathological Waste) t (J 0 l <br /> 41 <br /> a UN 3291,Regulated Medical Waste,N.O.S. <br /> 6.2, PG Il (Chemotherapy Waste) <br /> z <br /> Z Non-Hazardous Pharmaceutical Waste <br /> a_ <br /> s <br /> Non-Regulated <br /> Other(specify): <br /> A=Autoclave,1=Incineration, M=Microwave <br /> Advanced Chemical Transport,Inc. CA Hazardous Waste Registration:4026 <br /> 1210 Elko Drive, Sunnyvale, CA 94089 EPA ID#:CAR000070540 <br /> Motor Carrier Permit:0194741 <br /> LU <br /> ❑ 1210 Elko Drive ❑ 2010 Mission Ave. 265 Riggs Avenue ❑ 13722 Carmenita Road <br /> e1 Sunnyvale,CA 94089 Escondido,CA 92029 Merced,CA 95341 Santa Fe Springs,CA 90670 <br /> Z U. 408-548-5050 760-489-5600 209-722-4228 714545-2191 <br /> MWTS Permit#TS-42 MWTS FtErrpit#TS-106 MWTS Permit#TS-8 <br /> Print Na.me: I ,/I e(�v-aP2 Signature: Date: �` r1 <br /> u' <br /> a Name: DOT#: <br /> 00 <br /> Z Address: State Transporter#or Permit: <br /> in g <br /> Print Name: Signature: Date: <br /> I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> c marked and labeled,and are in all respects in proper Condition for transport according to applicable governmental regulations. I certify that this shipment does <br /> °a not Contain regulated hazardous and or radioactive waste. I am aware that there are significant penalties for submitting false information including the possibility <br /> wLL of fines and imprisonment. <br /> Z P0 Lu <br /> —t <br /> Signature:* Y v"L I Print Name: <br /> Advanced Chemical Transport ACT Medical Advanced Chemical Transport Advanced Chemical Transport <br /> 1210 Elko Drive 2010 Mission Ave- 265 Riggs Avenue 13722 Carrnentta Road, <br /> U O Sunnyvale,CA 94068 Escondido,CA 92029 Merced.CA 95341 i.'r'} Fp- —)ak 670 <br /> 408-548-5050 760.489.5600 209-722-4228 714545-2191 <br /> Z q MWTS Permit#TS-42 Permit#TSlOST-66 MJVTS Permil#TS-1 OO MNrrS Permit#T" <br /> N <br /> ~ THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE TRANSFER FACILITY CHECKED ABOVE. Signature&Date: <br /> ACT Medical Healthwise Services Medical E] Waste Management Healthcare ❑ Other <br /> 2010 Mission Road `fes Waste Disposal Solutions <br /> rr Escondido,CA 92029 i 4800 E.Lincoln Ave Fowler 4260 Bantlini Blvd <br /> t—G 760489-5600 California M25 Vemon,CA 90058 <br /> Permit#TSIOST-66 559-834.3333 3233070514 <br /> Irk Permit#TS-39 Permit#TS/OST-81 <br /> o THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE DESTINATION FACILITY CHECKED ABOVE. Signature Sr Date: <br />