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HealthWise Services <br /> 4800 E. Lincoln'tAve. �A lsllriuu�l rtr t <br /> fl EAU I HWI S E Fowler, CA 936.25 I �s!`I{y{i91a lllll4�lil� <br /> (559)834-3333 !ce¢l1n13�i1alStllti;4- 1€I <br /> S E R V - I C S 1Eillilll�lf,41it1 (�l �l <br /> Transporter Permit# 6070 <br /> Medical Waste Disposal Transfer Station Permit# TS-89 <br /> EPA# CAL000370179 <br /> CustomeriShipper Information Contact information <br /> t,olcllell 1,.411411g Il"elliei •4&,,?xkrott,gQ&,Wati Lone c+UMtV-00 41 24 HOUR EMERGENCY PHONE: <br /> Name: Site#: <br /> i40.tte':;���t�t��tic,I.,�iflt? CHEMTREC <br /> Address: Telephone; 1-800-424-9300 <br /> ;xtafi iron LA 9;a4101 Li) CCN723138 <br /> City: State: Zip: Route: <br /> Delivered to Customer-Clean Containers <br /> UN3291, Regulated Medical Waste, n.®.s., 6.2, PG II Y.:490-CAULNkly1-101.4 =;avt �- <br /> - <br /> Picked Up:From Customer",, '- <br /> 3 aNt ..11:Ar;eo;r�tsf��` ..,.,, ,...�:•.,-.... �,..w,� .,.�.., �. <br /> Container Qty. /1Neight Container City. Weight Container Qty. Weight Container oty. Wei ht Container Gity. Weight <br /> 20 � 20 <br /> 28 2a <br /> 38 38 <br /> 40 40 <br /> 44 <br /> 48 48 <br /> Its/ 96 <br /> SUB-TOTAL. 8Ua-1cTA1- SUI340TAL ....*US-TOTAL SUe-TOTAL <br /> 3 <br /> f <br /> K <br /> Signatures for Compliance and Authorisations <br /> .I hereby declare that are conte"[of this consignment are fully and accurately described I further declare that this shipment of waste is free.1 Notes,Comments,or Discrepancies <br /> above by pmpei,shipping nameand are classifed,packed,marked,andlabeled,,and are in hazardous and mercury wastes as defined by the 05 Total Containers:all aspects in proper condition fortransport.according:to applicable government regulations. Code of Federal Regulations and/or appropriate State <br /> Rules and Regulations. Total.Gross Weight: <br /> Minus Tare Weight: <br /> Total Net Lbs: <br /> 3 <br /> CustomerCustomer <br /> Name: al. Signature) < k '. Date: 9 d, 1" �f 1 <br /> (Plea FULL Name) '.(%easealg FULU.Nm¢) T^'�" - <br /> {y^l Route Driver fJ' j <br /> Route Driver. K i t t f.� h�s� Signature: r a '; r "t Date: t '— 1="-I I <br /> (Please Aunt FULL{Na¢ ) s (Please Sign FULL Ne >•) <br /> Transfer J Transfer Driver Alternate Designated Facility <br /> Driver: PnnSignature: Date: 1 ! <br /> (Please rFULL Nema) yPlease Sign FULL Name) <br /> Certificate of Receipt; Certification of receipt of Waste as covered by this tracking document number. <br /> Signature Date: <br /> Alternate Designated Facility <br /> 1 <br /> Certificate of Destruction:Certification of receipt and destruction of waste as covered by this tracking document number: <br /> Signature Date: 1 1 <br /> Ir <br /> Designated Facility Alternate Designated Facility Alternate Designated Facility Alternate Designated Facility Alternate Designated Facility Alternate Designated Facility <br /> HealthWise Services,LLC Curtis Bay Energy GulfWest Weste Solutions Superior Medical Waste Waste Management Healthcare Solutions <br /> 4800 E.Lincoln Ave 3200 Hawkins Point Road 7505 HlghWay 65 2671269 S.Arrowhead Ave 4280 Bandini Blvd <br /> Fowler,CA 93625 Baltimore,MD 21226 Anahuac,TX 77514 San Bernadino,CA 92408 Vernon,CA 90056 <br /> (559)834-3333 (443)692-2300 (408)267-3282 (600)973-4430 (323)307-0514 <br /> Permit#:TS-89 Permit#: 2005-WMI-0036 Permit#: 2239A Permit#: TS-123 Permit ft: TS/OST-81 <br />