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01/18/2017 831-1169001.2 0001892644 <br /> Medical Waste.Tracking Document Route No, T07 <br /> Customer. <br /> WIL1221 RO E OrERRTE Gi20LtP LLC 24-Ho3tr Emergency Response (800)424-9300 <br /> 1221 ROSE MARTS'Ltd. <br /> Stockton,CA 95207 Customer Service (855)508.0392 <br /> (209)477-2664 <br /> Description of Waste Container Type I yp No,of lit.or I <br /> Containers volume <br /> UI291,Regulated Medical Waste, N..O:S:,6:2,Pe3TI 43 GALLON(Regulated Medical Waste(6ioj)43 gal <br /> Transporter 1; <br /> Total Is <br /> WM.Healthcare Solutions,Inc. � -- i --�- <br /> 1496 Ran Lee PIaCe Ste.C Applicable Permits: <br /> Escondido-5688 MW-172 Phone#: (760)489-5009 <br /> Escondido,.CA 92029 Vernon-5688-MW-157 Phone#; (323)307-0514 <br /> Transpnrer w— nc� w <br /> S19na$UPapt of-Ma- t <br /> erials <br /> in$ +eP =dN3TE. Date <br /> Transporter' hermit# -��✓ -- Date' �' r <br /> Address Signature — <br /> -- Printed Name <br /> Autoclave j>ransfer Facility Transfer Facility incineration Facility Incineration facility Autoclave/Transfer Facility Alternate"treatment Facility <br /> WM Healthcare Solutions,Inc WM Healthcare Solutions,Inc Curtis Bay Energy <br /> 4280 Handini 9W 1996 Don Lee Place Suite c 3200 Hawkins Road Gulfwest Waste Solutions; Wtt Seattle Biomedical i Heaithwise Services <br /> LLC <br /> Vernon,CA 90058 Escondido,CA 92029 Baltimore MD 21226 14.9 SW Kenyon Street 4800 E.Lincolc Av. <br /> Phone(323)307-0513 Phone(760)48J 5009 Phone 4I0}354 3228 7505 state Hwy 65 Seattle,WA 98108 Fowler,CA 9367_S <br /> Pemtit# 75/OST 81 Permit(7 0)48 ( Anahuac,TX 77s14 Phone(206)505-9063 Phone(559)834.3333 <br /> Permit*.'.2011-WMI-0036 Phone(409)267-39.13 Permit#:PR0080378 Permit#:TS-89 <br /> Permit#:2239-A <br /> Signature (Signature Sinature <br /> Rate Date Date Date Signature <br /> Signature Signature -- <br /> — Date Date _ <br /> Discrepancy Treatment 1-acilitY certification of Receipt and Destruction <br /> "I certify that the contents of the listed container(s)have been received,treated,and <br /> disposed Of at one or more of the facilities indicated above in accordance with all local,state, <br /> and federal regulations.,' <br /> Comments <br /> i <br /> i <br /> Generator's certification:.n hereby declare,thatthe contents of this consignment are fully and accurately described above by the proper shipping name and are classified,packaged, <br /> marked and labeled/placarded,,and are in all respects in proper condition for transport by highway accord <br /> applicable state regulations." ing to applicable-international and national government regulations,including <br /> SigNiture <br /> Print/Typed Name _ 1 Date <br /> E <br />