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Regulated Medical Waste <br />TRACKING DOCUMENT# 2839562 <br />Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and <br />R <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 />p <br />23500 Kasson Rd Tracy, CA 95376 <br />� <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 />,� ^ <br />Jaime Moffatt <br />U v 03-04-2021 9:13 AM <br />N AM E OF COM PANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />NAMES) OF PERSON S COLLECTING, TRAN SPO RTIN G <br />O R ON LOADING 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 />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />O <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />03-04-2021 9:13 AM <br />a <br />Z <br />Pharm waste <br />Bio 38 gallon <br />¢� <br />oac m.e <br />ore. .. <br />o�c <br />c .. <br />an,. r <br />1 5 <br />1 15 <br />F <br />> <br />I 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 />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 />Q <br />/ <br />a <br />Evan Lieber <br />03-04-20219:13 AM <br />N AM E O F C O M PAN Y REPRESENTATIVE(Print) <br />SIG N ATTIRE O F REPRES EN TATIVE DATE <br />TRANffERSTATION: NAME <br />REGISTRATION NUMBER <br />NAME(S) OF PERSONS COLLECTING, TRANSPORTING <br />OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />N <br />W <br />C <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />n <br />Q <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />cc <br />H- <br />2 <br />O <br />#mnL <br />0 Cair. <br />fcont. WL r <br />scant M1 <br />F <br />I Certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load.] am aware that <br />¢ <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 />NAME OF COMPANY REPRESENTATIVE (Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />} <br />F <br />V <br />ADDRESS <br />Q <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL WEIG HT DEPOSITED/UNLOADED <br />w <br />Z <br />Z <br />Q <br />DISCREPANCY INDICATION SPACE <br />z <br />H <br />E <br />certify that I have been authorized to accept untreated medical wastes and that have received the above indicated wastes In accordance with the <br />Lu <br />g <br />requirements outlined in that authorization. <br />H- <br />Q <br />oc <br />NAME OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />In case ofemergency, call( 818 ) 998-5533 <br />(24 -hr company or other emergency response group telephone) <br />federal regulations. <br />