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l <br /> 03/22/2017 831.11690012 0001892653 <br /> Medical Waste Tracking Document Route No. TO <br /> Customer: <br /> GLGTR CHATEAU 24-Hour.Emergency Response (800.424-9300 <br /> 1221 ROSE MARXE'LN <br /> Stockton,CA 95207 Customer Service (855)508.0392 <br /> (209)477-2664 <br /> jDesa7ption of Waste Container Type - - � No.of Ib,or i <br /> Containers Volume l <br /> UN3291,Regulated Medical Waste,MOS.,6.2,PGII 43 GALLON(Regulated Medical Waste(Bio))43 gal <br /> Transporter l: Totals <br /> WM Healthcare Solutions,Inc. Applicable Permits: _ <br /> I _ <br /> 1996 Don Lee Place Ste.C Escondiido-5M-MW-172 Phone•#: (760)489-5009. <br /> Escondido,r A 92029 Vernon-5688-MW,157 Phone#: (323)307-0514 <br /> S ansporter i At ftt letigeeirtsl9t of Recefpt of Materials' ; <br /> s <br /> Print/Typed Name e. ; i Date <br /> 7 <br /> Transporter — permit# — ---- — Date --- <br /> Address Signature <br /> Printed Name <br /> Autoclave/Transfer;Facility Transfer Facility Incineration Facility Indneration Facility Autoclave/Transfer Facility Alternate Treatment Facility <br /> WM Healthcare Solutions,Inc WM Healthcare Sdiutions,Inc Curtis Bay Energy Gulfwest Waste Solutions, WM Seattle Biomedical Healthwise Services <br /> 4280 Bandinf Blvd 1996 Don Lee Place Suite C 3200 Hawkins Road LLC 149 SWKenyon Street 4800 E.Uncoic Av. <br /> Vernon,CA 90058 Escondido,.CA 92029 Baltimore,iVID 21226 7505 State Hwy 65 Seattle,WA 9810E Fowler,CA 93625 <br /> Phone(323)307-0514 Phone(760)489=5009 Phone(410),354-3228 Anahuac,TX 77514 Phone(206)505-9063 Phone(559)834-3333 <br /> Permit# TS/0ST 81 Permit#:TS-73 Permit#:2MI-WMI-0036 Phone.(409)267-3913 Permit#:P110080378 Permit#:TS-89 <br /> Permit#:2239-A <br /> Signature Signature Signature Signature Signature Signature _ <br /> Date Date Date Date Date Date <br /> Discrepancy Treatment Facility 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 ormore of the facilities indicated-above in accordance with all local,state, <br /> and federal regulations." <br /> Comments <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,packaged, <br /> maiked.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 Date <br />