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Regulated Medical Waste <br />_ TRACKING DOCUMENT# 2819269 <br />Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated In accordance with applicable <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x X5513 <br />ADDRESS <br />O <br />23500 Kasson Rd Tracy, CA 95376 <br />Q <br />I certify that the information provided is true <br />and correct, and that the generated materials are properly classified, described, <br />Z <br />packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br />U.S. Department of Transportation. <br />Jaime Moffatt <br />V — 02-25-2021 9:13 AM <br />N AM E O F CO M PAN Y REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />NAME(S) OF PERSONS COLLECTING, TRANSPORTING <br />OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Med-Waste Systems, LLC <br />(818) 998-5533 <br />¢ <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />0 <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />02-25-20219:13 AM <br />u <br />Z <br />Bio 38 gallon <br />Pharm waste <br />ant .n.. <br />�c + <br />�t ° <br />sco"r. <br />t .w <br />5 112 <br />5 39 <br />certify that the information provided above Is true <br />and correct and that only untreated medical wastes are contained in this load. I am aware that <br />CC <br />falsification of this tracking document may result in <br />forfeiture of my transporer's registration and/or the privilege of utilizing State- authorized facilities. <br />Q <br />a <br />Evan Lieber <br />02-25-2021 9:13 AM <br />N AM E O F C O M PAN Y REPRESENTATIVE(Print) <br />SIG N ATU RE O F REPRESEN TATIVE DATE <br />TRANSFERSTATION: NAME <br />REGISTRATION NUMBER <br />NAME(S) OF PERSO N S CO LLECTING, TRAN SPO RTING <br />O R ON LOADIN G WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />rV <br />z <br />¢ <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />d <br />Lo <br />Z <br />Q <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />K <br />F- <br />2 <br />O <br />nc a1 <br />COflL MA <br />#Mnt MA <br />H <br />I certify that the information provided above Is true and correct and that only untreated medical wastes are contained in this load. I am aware that <br />to <br />W <br />falsification of this tracking document may result in <br />forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. <br />Z <br />Q <br />F_ <br />NAME OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />COMPANYNAME <br />TELEPHONE NUMBER <br />} <br />F- <br />Zi <br />U <br />ADDRESS <br />Q <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />Z <br />Q <br />DISCREPANCY INDICATION SPACE <br />z <br />H <br />F <br />Z <br />I certify that I have been authorized to accept untreated medial wastes and that I have received the above Indicated wastes In accordance with the <br />g <br />requirements outlined In that authorization. <br />F <br />oc <br />NAME OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />In <br />case of emergency, call (_818 ) 998-5533 <br />(24 -hr company or other emergency response group telephone) <br />local, state, and federal regulations. <br />