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01/29/2019 831-13710001 0002124517 <br /> ® Medical ante Tracking Document Route No. „x207 <br /> Customer: <br /> DTH QUAIL LAKE' 24-Hour EmergencyR i ponce (800)424-9300 <br /> 1221 Rosemarie Ln <br /> Stockton,CA 95207-6703 Customer Service-, (855)508-0392 <br /> (209)477-0271 <br /> Description of Waste Container Type :, No.of Ito.or <br /> Conta'i ers Volume <br /> UN3291, Regulated Medical Waste,N.O.S.,6.2,'PGII 43 GALLON(Regulated Medical Waste(Bio))43.000000 gal <br /> Transporter 1: Totals <br /> WM Healthcare Solutions,Inc. Applicable Permits: <br /> 1996 Don Lee Place Ste.C Escondido-5688-MW-172 Phone#: (760)489-5009 <br /> Escondido,CA 92029 Vernon-5688- MW-157 Phone#: (323)307-0514 <br /> Transporter 1 Acktt®WledgemeV of Re ipt of Materials , <br /> Signature �aJ Print/Typed Name J6',r�" i I'` �'t"l Date / `r <br /> Transporter r• Permit# Date <br /> Address_ Slgnahire <br /> Printed Name <br /> AutodavelTransfer Facility Transfer Facility Incineration Facility Incineration Facility Alt Treatment Facilitv .1)(0cessiniarMS <br /> WMHS Vernon WMHS Escondido Covanta Energy HESI Services Aemerge RedPak d Healthwise Services <br /> 4260 Bandini Blvd 1996 Don Lee Place 5251 Triana Blvd SW 1420 40th Street North Services S.C.,LLC 4800 E.Lincoln Av. <br /> Vernon,CA 90058 Suite C Huntsville,AL35805 Fargo,ND 58102 9600 E.Avenue j Fowler,CA 93625 <br /> Phone(323)307-0514' Escondido,CA 92029 Phone(256)882-1019 Phone(701)282-7373 Hesperia CA,92345 t Phone(559)834-3333 f <br /> Permit#: TS/OSr 81 Phone(760),q89.-5009 Permit#:709-1104 Permit#:ITS-0203 Phone(760)983-2808 Permit#:TS-89 _ <br /> Permit#:TS-73 Permit#:TS/OST 135 N,\ J <br /> .Signature_- SignatureSignature Signature Signature- <br /> Date <br /> ignature Date Date Date Date Date Date <br /> Iscrepancy Treatment Facility Certification of Receipt and Destruction <br /> "I certtfy that the contents of the listed contalner(s)have been received,treated,and <br /> disposed of atone or more of the facilities indicated above in accordance with all local,state, <br /> and federal regulations." <br /> omments <br /> eneratoes Certification:"I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are ciasstfred,package <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,Includln <br /> applicable state regulations,; <br /> ignature Print/Typed Name "' "' h `�'` "' Date <br /> 900 'd 'ON Xdj Nd ZO : ii M/610Z/1Z/9H <br />