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l <br /> p 02[1\5/220--177 831-11690012 0001903214 i <br /> Y V <br /> Medical Waste Tracking Document Route No. Tal i <br /> Customer: <br /> 1221 ROSE MARIE LN <br /> R CHATEAU 24-Hour Emergency Response (800)424-9300 <br /> 3.221 <br /> Stockton,CA 96207 Custamer Service (855}S08-0392 I <br /> (209)477-26.64 <br /> Description of Waste Container Type No.of to.;r <br /> Containers Volume <br /> Pharmaceutical Waste, Pharrrlaceutica6 Waste 110 GALLON SHARPS CONTAINER(Pharmaceutical Waste)10 gal <br /> Transporter 1: Totals <br /> WM Healthcare Solutions,Inc: Applicable Permits: — <br /> 1996 Don Lee Place Ste..C Escondido-5688-MW-1.72 Phone.#: (760)489-5009 <br /> Escondido,CA 92029. Vernon-5688-MW-157 Phone#: (323)307-0514 <br /> ESIgnature <br /> porter 1 Acknouvledgement of�Receipt of Materials <br /> \ r: /'` Print/Typed Name ,_j <br /> r Fr? Date <br /> Transporter-2 %' Permit# <br /> s jr— _ Date. <br /> Address Signature -- <br /> -- ------ _ Printed Name - <br /> Autodave/Transfer Facility Transfer Facility incineration Facility Incineration Facility Autoclaveriransfer Fadlity Alternate Treatment Facility <br /> WM.Healthcare Solutions,Inc WM H@althcare Solutions,Inc curtis Bay Energy Gulfwest Waste Solutions, WM Seattle Biomedical Healthwise Services 1 <br /> 4280 6andini Blvd 1996 Don Lee Place Suite C 3200 Hawkins Road ilii <br /> Vernon,CA 90058 Escondido,CA 92029' Bditimore,NtD 21226 C 149 SW Kenyon Street 4800 Lincoic Av. <br /> Phone(323)3137-0514 phone(760):489-5009 Phone re, 21 2 6 7505 State Hwy 65 Seattle,WA 98108 r Fowler,CA 93625 <br /> Permit.#. TSIPST 81 Permit#:TS-73 Anahuac;TX 77554 Phone(206)505-9063 Phone(559)834-3333 <br /> Permit#:2011-WMI-0036 Phone(409)267-3913 Permit#.:PR0080378 Permit#:TS-89 <br /> Signature , <br /> Sig Signature _ Signature, Permit#:223g-11 <br /> Date <br /> _ Signature Signature_ Signature. <br /> Dake bate Date Date Date _ <br /> Discrepancy Treatment Facfiity 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 /> Camirtents <br /> Generatoes.Certifiration:"I hereby declare that the cbntets of this consignment are fully and accurately described above by the proper shipping name and are classified;,packaged, <br /> marked andlabeled/placarded,and are in all respects in proper condition for transport by highway according <br /> applicable state regulations" to international and national government regulations,including <br /> J <br /> Signaturel/ r <br /> PrIntJTygled NamB 'r ,�( ! mate / {~ '/7 <br />