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N C9 N (9 (D MedWaste MSA <1 , - EPA#CAL000373155 INFECTIOUS jNAST'E TRACICIIdG DOCUIISENT � INSPRUCTIOl\SFOR OOMPLET'ING IIQFBC3gOUS�1'ASTETRACi�'G a 1.Gej)enerator's Name and Mailing Address: 2,Traclung Dua meat Number: Q ��I GBIr`ERATOA COPT:Marled by Destination Facility m Generator DOCUMENT -� Copy 2-TRANSPORTER COPTS Retained by Transporter d1 1 V Copy 3-GENERNTOR COPE:Retained by-Generator _t r Copy 4-TREAZ7viEA'T FACILITY COPY:Retained by Treatment Facility J� / A.Account A`ttmber: !.- - tis ( I.This mu]ticopf•(4 page)shipping dacamenr must accompany each shipment of infectious waste `�J- .�=`# --------- �' 2.Itemsnutnhered I-14 musl be completed before e WW 3.Telephone Numbers( ) , state the name rethe th generator can sign(Ile certification.item 15 must original generator.Item 22 must be completed by the destination facility. v S.Tran Portees Name and Mailing Address, 6.Telephone Number. 16.Transporter°s Certificatiotl n MedWaste USA 510-250-Q911 f I certirT,under penaltp afcrinsind and orcivil prosecution far making or suhn inion affahe utfinents: Q P.O.$ax 22840 7.State ( replesenations,or orflissions,that 1 have read.understood,arid:well cnmplywith the U.S-Department of Qaldancl,CA 94609 6090 ID No.: E-i TYanspartation 49 CFR Parts 100.397. CQ 6090 _ r DOT/IOC _ _ ` Printed/Typed Name 8.Vest ination Facility Name and Address: _ _ , A 9•Tpele ]stone A timber Q Health14rise Services : 17.Transporter 2 or Intermediate Handler- 18.Telephone Number: 4SQ0 E Lincoln Avenue 559-834-3333 Q (nameaodaddreae) ( ) W 10.State Permit or ID—No M q Fci•Wler.CA 93625 TS-94 E t 9.State Imnsporter Permit or ID No: 11.LIS DOT Description: DOT/ICC (Indo 12. Na. 13.Total 14reigltt: I'1°peir `pin$namr,hazarddass,andl-D.nttmber) Containers- 20.Transporter 2orrntermediLite Handler:(ceBuna�naafpcnycufln�austy u alimc17,i1.�ts) a Regulated Medacal%t,e(M'3291,Gass 6.2 PG 11) - - .1) i y i A, c.-, b.NON-Hazardous Pharmaceutical lArasteC cr` 4d e t lgrra rn c.Other(Chemo,Path) 21.New 1Yacltitlgo Document Number:'(Far comulldarerl w remaoifeated waste) 14.Special handling instructions: 22,Destination FaCll;ty:(CErtrGratlun df RecdV of]infectious Wasre is described in imus 11,12,&13) Q Items 1-14 must be&fled out before generator signs Item 15l ZLO 15.Generato?s CerEification: O M N L0 This is to certify that the above name materials are properly dassi&ed,described,packaged.tttarked � Pritated!•Typed Name Signature Date -- N and labeled,and am in propereondition for transportation according to the applicable F%Wations N of the Department ofTra tCertificanno ofadequate treamteni aflr,fe,3iWs IYFste u desrrib in items 11,12,k i3) � nsportatiau. m Under penalty afcriminal and civil prosecution for the making or submission of false statemeltts, N tePresentattons,ar�lnissions,I declare,on behalfofthe generator,that the contents of this W C-4 consignment are fully and accurately described above and are classified,packaged,marked and Q printed/7-pBd None labeled in accordancr*ith the State of California and U.S.Department of Transportation 49 signature Date c� CPR Parts 100-180,that this sbipmertt does not contain regulated quantifies of RCRA hazardous 23.Discrepancy Box:(_as;y 7e and or ndioac ve waste.I am asyare that there ares' F -}should be Waged by]cern nwnher asci initials) information including the possibkty of fines and imptgesanratenetnalties for submitting false ¢ ao m r - E Printed!Typed Name . ;'5 ature m Y Date a N N Copy I-GENERATOR COPY..hlailed by Destination Facility to Generator(Wii1TE copy) - Copp 2-TRAR'SPORTBR COPY:Retained by Transporter(YELLOW copy) CD Capt•3-GENEHATOR COPY Retained by Generator(PINK copy) - Copy 4-TREATMENT FACILI- TY COPT':Retained by Treatment F®cility(GOLD Copy)