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Regulated Medical Waste <br />TRACKING DDCUMENTp 2960352 <br />' ( <br />Cert <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />COMPANY NAMETELEPHONE <br />NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x X5513 <br />ADDRESS <br />p <br />23500 Kasson Rd Tracy, CA 95376 <br />I certify that the information provided is true <br />and correct, and that the generated materials are properly classified, described, <br />packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br />Z <br />Z <br />W <br />U.S. Department of Transportation. <br />Jaime Moffatt <br />03-11-2021 10:14 AM <br />N AM E OF COM PAN Y REPRESENTATIVE(Print) <br />SIGNATURE or REPRESENTATIVE DATE <br />NAME(S) OF PERSON S COLLECTIN G, TRAN SPORTIN G <br />OR 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 />w <br />cc <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED. <br />OQ <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />03-11-2021 10:14 AM <br />Z <br />Bio 38 gallon <br />coat. -4 - <br />n,. r <br />OM r <br />rtconL <br />0 0 <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 />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 />4 <br />: <br />y / <br />� <br />a <br />Evan Lieber <br />C 03-11-202110:14 AM <br />NAME OF COMPANY REPRESENTATIVE (Print) <br />SIG N ATURE O F REPRESEN TATIVE DATE <br />TRANSFER STATION: NAME <br />REGISTRATION NUMBER <br />NAME(S)OF PERSONS COLLECTING, TRAIN SPORTIN G <br />OR ON LOADIN G WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />tV <br />W <br />Evan Lieber <br />EL <br />z <br />COMPANY NAME <br />TELEPHONE NUMBER <br />a <br />(Stockton) Med-Waste Systems, LLC <br />(818) 998-5533 <br />Z <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />Q <br />Fes- <br />4079 Cherokee Ln Stockton CA 95215 <br />03-11-202111:10 AM <br />z <br />Bio 38 gallon <br />o <br />tl <br />one e <br />OM .. <br />t <br />ani A <br />F <br />00 <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 />tzt <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 />LL <br />�I <br />Z <br />Evan Lieber <br />` 03-11-2021 11:10 AM <br />r <br />NAME OF COMPANY REPRESENTATIVE (Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />F_ <br />Healthwise Services <br />(559) 834-3333 <br />U <br />ADDRESS <br />< <br />4800 E Lincoln Ave Fowler CA 93625 <br />PERMIT NUM BER <br />DATE WASTE WAS DEP051TED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />TSOST-89 <br />03-12-2021 2:30 PM <br />Z <br />DISCREPANCY INDICATION SPACE <br />Q <br />K <br />F <br />H <br />Z <br />I certify that I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the <br />:�i <br />requirements outlined in that authorization. <br />j'� <br />w/'` <br />Edgar Ramirez <br />03-12-2021 2:30 PM <br />r <br />F_ <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 />