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Regulated Medical Waste <br />TRACKING DOCUMENT# 2953841 <br />Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above Is treated <br />CODE AREA <br />7 <br />UN3291, Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />YA. dam.. <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 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 />� <br />packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br />Z <br />W <br />U.S. Department of Transportation, <br />6X"� <br />� 04-15-2021 9:07 AM <br />' <br />Mike Margullis <br />NAME OF COM PAN Y REPRESENTATIVE (Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />NAME(S) OF PERSON S COLLECTIN G, THAN SPORTING <br />O R UN LOADING 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 />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />0 <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />04-15-2021 9:07 AM <br />Z <br />Ph On waste <br />„L WtA <br />¢ <br />1 8 <br />F <br />}� <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 />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 />(/ <br />a <br />Evan Lieber <br />`-- 04-15-2021 9:07 AM <br />NAME OF COM PANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />TRANSFER STATION: NAME <br />REGISTRATION NUMBER <br />NAME(S) OF PERSONS COLLECTING, TRANSPORTING <br />OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />rV <br />rrr <br />Evan Lieber <br />EL <br />COMPANY NAME <br />TELEPHONE NUMBER <br />a <br />(Stockton) Med-Waste Systems, LLC <br />(818) 998-5533 <br />Z <br />DATE MEDICAL WASTE COLLECTED <br />ADDRESS <br />4079 Cherokee Rd Stockton CA 95215 <br />04-15-2021 10:01 AM <br />Z <br />Pharm waste <br />„om. �n., <br />a,o�. .rt. , <br />o�� , <br />„ m. <br />8 <br />are contained 1n this load.I am aware that <br />NI <br />certify that the Information provided above is true <br />and correct and that only untreated medical wastes <br />of <br />falsification of this tracking document may result in <br />forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized fad lities. <br />04-15-2021 10:01 AM <br />Z <br />Evan Lieber <br />N AM E O F CO M PAN YREPRESEN TATIVE(Print) <br />SIG N ATURE O F REPRES EN TATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />I}- <br />Healthwise Services <br />(559) 834-3333 <br />U <br />ADDRESS <br />< <br />4800 E Lincoln Ave Fowler CA 93625 <br />W <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />LL <br />TSOST-89 <br />04-15-2021 12:27 PM <br />8.00 <br />Z <br />DISCREPANCY INDICATION SPACE <br />Q <br />K <br />F - <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 />W <br />g <br />requirements outlined in that authorization. <br />E- <br />f / <br />c <br />< <br />Rafael Carrillo <br />04-15-2021 12:27 PM <br />F- <br />NAME OFCOMPANY REPRESENTATIVE(Print) <br />SIGNATUREOF REPRESENTATIVE DATE <br />In <br />case of emergency, call(_M) 998-5533 <br />(24 -hr company or other emergency response group telephone) <br />in accordance with applicable local, state, and federal regulations. <br />