Laserfiche WebLink
Regulated Medical Waste <br />TRACKING DOCUMENT 2973344 <br />Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in acco <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />7.f. OJ(aaA. ^nGde.. <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x 5513 <br />ADDRESS <br />p <br />23500 Kasson Rd Tracy, CA 95376 <br />I certify that the information provided is true 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 />U.S. Department of Transportation. <br />P\ � �Any,,,(Ylrt� <br />Mike Margullis V 04-22-2021 9:44 AM <br />NAM E O F COM PANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br />N AM E(S) OF PERSONS COLLECTING, TRANSPORTING OR UN LOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Or <br />Med-Waste Systems, LLC: <br />(818) 998-5533 <br />F_ <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTEDOf. <br />0 <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />04-22-2021 9:44 AM <br />z <br />Bio 38 gallon <br />r.2 ,Kr <br />o�c r <br />m. .e <br />n <br />24 <br />F <br />y� <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 forfeiture of my transporter'sregistration and/or the privilege of utilizing State -authorized facilities. <br />Evan Lieber L ` 04-22-20219:44 AM <br />a <br />N AM E O F CO M PAN Y REPRESEN TATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br />TRANSFER STATION: NAME <br />REGISTRATION NUMBER <br />NAME(S)0F PERSONS COLLECTING, TRANSPORTING O R UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />N <br />w <br />¢ <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />Q. <br />Z <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />Q <br />tt <br />F- <br />O <br />ont ak <br />cbnt. wtJ <br />acunt <br />am. wt.0 <br />F <br />I certify that the information provided above is true and correct and that onlyntr ae ted medical wastes are contained in this load. I am aware that <br />v¢~i <br />W <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 />Z <br />NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br />F <br />COMPANYNAME <br />TELEPHONE NUMBER <br />F- <br />U <br />ADDRESS <br />Q <br />F6} <br />¢ <br />PERMIT NUMBER <br />DATE WASTE WAS DEP051TED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />Z <br />DISCREPANCY INDICATION SPACE <br />Of <br />F- <br />F <br />Z <br />I certifythat I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the <br />requirements outlined In that authorization. <br />F - <br />Q <br />F- <br />N AME O F COMPANY REPRESENTATIVE(Print) SIG NATURE OF REPRESENTATIVE DATE <br />Incase of emergency, call ( 818 ) 998-5533 (24 -hr company or other emergency response group telephone) <br />rdance with applicable local, state, and federal regulations. <br />