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11/20/2018 831-13710001 0002097163 <br /> ® Medical Waste Tracking Document Route No. TR207 <br /> customer: <br /> DTH QUAIL LAKE 24-Hour Emergency Response (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 Ib.or <br /> Containers Volume <br /> UN3291,Regulated Medical Waste, N.O.S.,6.2, PGII 43 GALLON(Regulated Medical Waste(Bio))43.000000 gal <br /> ° Lir <br /> Transporter 1: Totals f <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 Acknpwledgement of-Receipt of Materials <br /> Signature � , �� Print/Typed Name C-. ,7., ..J a l Date /^ ,?,4.— f�, <br /> Transporter 2Y Permit# ` ✓ Date <br /> Address Signature <br /> Printed Name <br /> r' <br /> Autoclav ansfer Pacil" Transfer FacilityIncineration Facility, Incineration Faclll Alt Treatment FacilityFPocessin S <br /> WMHS Vernon WMHS Escondido Covanta Energy HEST Services Aemerge Red Pak Healthwise Services <br /> 4280 Band"rni Blvd 1796 Gon Lae Place: 5251 Trlana Blvd SW 1420 40th Street North Services S.C.,LLC 4800 E.Lincoln Av. <br /> CA 90058 Suite C Huntsville,AL 3580 <br /> Vernon,Ve5 Fargo,ND 581OZ 9600 E.Avenue Fowler,CA 93625 <br /> Phone(323)307-0514 Escondido,CA 92029 Phone(256)882-1019 Phony(701)282.7373 Hesperia CA,92345 Phone(559)834-3333 <br /> Permit#: TS/OST81 Phone(760)489.5009 Permit#:709-1104 Permit#:ITS-0203 Phone(760)983-2868,Permit#:TS-89 <br /> Permit#:TS-73 Permit#:TS/OST 135 <br /> SignatureSignature Signature Signature Slgnature Signature <br /> Date Date Date Date Date Date <br /> )iscrepancy Treatment Facl ty Certification of Receipt and Destruction <br /> "I certiry that the contents of the listed contalner{S)have been receivers,treated,and <br /> disposed of at or more of the facilities Indicated above In accordance with all local,state, <br /> and federal regulations." <br /> :omments <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,package <br /> narked and labeled/placarded,and are in all respects in proper condition for transporl,?y highway according to applicable international and national government regulations;Includln, <br /> hpplicable state regulations." ; <br /> Signature Print/Typed Name Date <br /> l0 'd 'ON Xdd AV 51 : 11 IIHI/6I0U AHS <br />