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CV CD 04 W Q WYa S 'e USA n EPA#CAL0003731 b3 INFECTIOUS WASTE TRACKING DO CUMEWZ mism)CTIONS FOR COMPLETING INFECTIOUS WASTE TRACKING DOCUI�TT 1.Gegerator's Name and Maibn Address: 2.Tracking Document Number: O Copy I-GENERATOR COPY:Malted by Destination Facility to Generator g P-c Copy 2-TRANSPORTER COPY Retained by Transporter ' j) { 0, j .� ! 5913 U Capy 3-GE.T-R-&MR OOPY,Retained by Generator (+. t ` d Copp 4-TREATMENT FACILITY COPY:Retained by Treatment fatality 4.Account Number: H .This muiticopy(4 page)shipping doetmientmustaccampaoyeatisbipmentofinfedauswasle t S ' e�� 2.Items numbered 1-14 must be completed before the generator can sign the certification-Item 15 must 3.Telephone Number: Q ( } f Ab - -- - state the name of the original generator.Item 22 must be completed by the destination facility U 16.Trausporter's Certification: !tone Number: A5.Transpart�r's Name and Mailing Address: 6.Telephone I certify,under penaltpof criminal and arcivil prosecution for maidrtg or subruissinn of false statements, Z MedWaste USA 510-250-0911 represenalions,or omissions,that I hate read,understood,and will comply pith the US.Department of Q P.O.Box 22840 7.State Transporter ID No.: lranspormtion 49 CFR Pares 1110-397_ Q Oakland,CA 94649 6090 W DOT/1CC_ � _ _ — ^ _ PrintedlTlpedMame Signature Date orter 2 or Intointediate Handler: 18.Telephone Number: a 8.I?esnafion Facllitp Name and Address: 9.Telephone Number: z17.'Brans 1? H J A�4 HealthWise Ser%,ces 539-934-3333 4 (name and address) ( } Q 4800 E,Lincnin Avenue 10.State Permit or ID No.: H 19.StateRanspatter Permit or 11)No: T-diner,CA 93625 TS-94 DOT/ICC 13.US DOT Description: 12.Total No. 13,Total Weight. 2Q,Transporter 2 or Intermediate Handler:(Cff9o1i1r:u'Racgtmftruau3xnc wfta;de AW—inurm;I L,1-7&13) (Including proper shipping name,hazard class,and I.D.number) Containers: � � 7 a.Regulated Medical Waste(UN3291,Class 6,2 PG 11) WMd/ P l C31b.NON-Hazardous Pharmaceutical Waste i atu �Daie G 011ier(Chemo.Path) 21,Ne%Traelttng Document Number:(Forcomolidated ornmwaestedwasie) o 0 14.Special Handling Instructions: Z+ 22.Destination Facility:(Certifimltorn of Rwetpt aflydedioas waste as descolped in[taus 11,121&13)CIO z Items 1-14 must be filled out before generator signs Item 151 c � M 15.Generator's Certifican;tio1 4 Printed/T}pM Name Signature Date M v This is to certify that the abode name materials are properly classified,described,packaged,marked �` a-' CV N and labeled,and are in proper condition for transportation according to the applicable regulations (Cerhcatsan of adequate treatment of Infrctious Waste u dumhed in items 11.12.&13) moftheDepartment of Transportation- E.s N Under penalty of cAminal and civil prosecution for the mating or submission of false statements. Lei o re sexxtadom,or on3issions,l declare,on behalf of the enerator,that the contents of thin "' g A printed I Typed Name Signature Date consignment are Eirlty and accurately described shove and are classified,pack-aged,marked and . labeled in accordartaewith the State of California and US.Department of Transportation 49 `~ m CFR Parts tom 8U,that this shipment does not contain regulated quantities of RCRA hazardouSCrepancys 'Di Box (Any dsscttpaucy shoald be Hood lm item nwober and inroals) y and or radioactive waste.I am aware that there are sigpibcantpenalties fax submitting falm m information indisding the possibility offines and imprisonment. Q ,--t �__ ...1 ,. - 1✓ -c; Lam. . � /Vi� f i c.r � CD Printed/Typed Name "S ature Date Cv m Copy 1-GENERATOR COPY:hfailed by Destination Facility to Generator(WHITE copy) v Copy 2-TRANSPOR'TER DOPY:Retained by Transporter(YELLOW dopy) a' m Copy 3-GENERATOR COPY.,Retained by Generator(PINK ropy)- Copp 4-TREATMENT FACILITY COPY:Retained by Treartment Facility(GOLD Copy) �