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03/08/2017 831-11640012 0001$92551 <br /> VW^4&,.E A� � T" Medical <br /> Waste Tracking Document Route No. T07 <br /> Customer. <br /> GLCTR CHATEAU <br /> 1221 Rc)sE:MARIE LN 24-14our(Emergency Response (800)424-4300 <br /> Stockton,CA 95207 <br /> Customer Service (855)508-0382 <br /> (209)477-2664 <br /> DescripEiotlof Waste Container Type No.of Ib.or <br /> UN3291L Regulated Medical Waste,N.o,5,,;6.2,PGII 43 GALLON(Regulated Medical Waste(Bio))43 gal Containers Volume <br /> -------------- <br /> / s <br /> Transporter lE <br /> WM,Healthcare solutions,inc. Totals <br /> Applicable Permits: <br /> Esj-- <br /> Escondoti lee Place Ste.C Escondido_5688 MW-172 Phone#: (760)489-5009 <br /> condido,CA 42429 Vernon-5688-MW-157 Phone#: (323)347-0514 <br /> Trans <br /> porter 1 AdCriowi <br /> ed,e, ernt of�ceipt of Materials 2 <br /> ig <br /> Snature . Print T ��q <br /> l YN °°1®a!t{e J_ ! L' f •� /\ ? ,�! Date <br /> Transporter,2:� _ <br /> Permit# <br /> Addreo, Signature Date <br /> Printed Name _ <br /> AutoclaiW Tran5ferFacillty TransferFacili <br /> Facility Incineration Padfity Incineration Facility Autodave/Transrer Facility Alternate Treatment'Facility <br /> Whi Healthcare Solutions,Inc Wk Healthcare solutions inc: L17rtis Bay Energy Gulfwest Waste Solutions, WM Seattle Biomedical Healthwi5e Services <br /> 4280 8andini Blvd 1956 Don Lee Place Salle> 3200 i iawklris Road ��� <br /> Vernon,CA 90058 Escondido,CA 92029 8alGmore;MQ 21226 LLC 149 SW Kenyon Street 4800' E.Lincolc Av. <br /> Phone(323)307 0519 Phone(760)489°5009 Phone. 910 3543228 7505 State Hwy 65 Seattle,WA 98108 Fowler,CR 93625 <br /> Permit :., TS/OST 81 Permit#:TS-73' ( ) Anahuac,7X 77514 Phone(Zpb)505 90b3 Phone(554)834-3333 <br /> Permit#1 207:2-WI MI-0036 Phone(409)267,3913 Permit C PR0080378 Permit :TS-n <br /> Permit#;2239-A <br /> Signature Signature. <br /> Date: ^ - — SI nature <br /> —_� Date Date Signature_ Signature _,� Signature <br /> Date Date Date <br /> Discrepancy — <br /> TreammentFacilityCertificationof Peceipt 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 /> generator's CertifiCationi"I hereby:declare that'the contents of this consignment are t1ly and accurately described above Uy 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 according to applicable international and national government regulations,including <br /> applicable.state regulations." <br /> Signature <br /> _ Print/Typed Name . <br /> Date <br />