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A Regulated Medical Waste <br />TRACKING DOCUMENTU 2839562 <br />Cert <br />CODE AREA <br />UN3291, <br />Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />�. qy„aV564�wm <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 z X5513 <br />ADDRESS <br />p <br />23500 Kasson Rd Tracy, CA 95376 <br />ti <br />Icertify that the information provided is true and <br />correct, and that the generated materials are properly classified, described, <br />Cc <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 v 03-04-2021 9:13 AM <br />N AM E OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE O F REPRESENTATIVE DATE <br />NAMES) OF PERSON 5 COLLECTING, TRAN5PORTIN G OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />W <br />Med-Waste Systems, LLC <br />(818) 998-5533 <br />¢ <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />03-04-2021913 AM <br />Q_ <br />U1 <br />Pharm waste <br />Bio 38 gallon <br />anet%V1.9 <br />nnL .. <br />as <br />4 cort, WL# <br />9cont <br />5 <br />1 15 <br />H <br />> <br />Icertify that the Information provided above istrue and <br />correctand that only untreated medical wastes are contained In chis load. lam aware that <br />G <br />falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State- authorized facilities. <br />t L <br />a <br />Evan Lieber <br />03-04-2021 9:13 AM <br />N AM E O F CO M PAN Y REPRESEN TATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />TRANSFER STATION: NAME <br />REGISTRATION NUMBER <br />NAME(S) O F PERSON S COLLECTM G. TRAN SPO RTING O R UN LOADIN G WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />N <br />w <br />Evan Lieber <br />EL <br />¢ <br />COMPANY NAME <br />TELEPHONE NUMBER <br />0- <br />(Stockton) Med-Waste Systems, LLC <br />(818) 998-5533 <br />Q <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />F- <br />4079 Cherokee Ln Stockton CA 95215 <br />03-04-2021 10:46 AM <br />Z <br />Pharm waste <br />Bio 38 gallon <br />O <br />nLn <br />c <br />s <br />anL .. <br />F_ <br />1®5 <br />1 15 <br />I certify that the information provided above Is true and <br />correct and that only untreated medical wastes are contained In this load. I am aware that <br />¢ <br />falsification of this tracking document may result in forfeiture of my transporter's regFtrattiion and/or the privilege of utilizing State -authorized facilities. <br />Z <br />Evan Lieber <br />`-- `— 03-04-2021 10:46 AM <br />NAME OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Healthwise Services <br />(559) 834-3333 <br />J <br />ADDRESS <br />u <br />4800 E Lincoln Ave Fowler CA 93625 <br />w <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTALWEIGHT DEPOSITED/UNLOADED <br />TSOST-89 <br />03-04-20212:10 PM <br />20.00 <br />z <br />DISCREPANCY INDICATION SPACE <br />K <br />F- <br />F <br />Z <br />Icertify that I have been authorized to accept untreated <br />medical wastes and that I have received the above indicated wastes in accordance with the <br />2irequirements <br />outlined In that authorization. <br />H <br />w <br />Rafael Carrillo <br />/ �� 03.04-2021 2:10 PM <br />r <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 />ificate of Destruction: Med-Waste. Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations. <br />