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Regulated Medical Waste TRACKING DOCUMEMk 3011575 Cert CODE AREA UN3291, Regulated Medical Waste, 2275 n.o.s., 6.2, PGII COMPANY NAME TELEPHONE NUMBER DVI-Deuel Vocational Institution (209) 835-4141 x5513 ADDRESS p 23500 Kasson Rd Tracy, CA 95376 I certify that the information provided is true and correct, and that the generated materials are properly classified, described, � Z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the U.S. Department of Transportation. \r.A o��,, CU 05-06-20219:01 AM Y"—"'- ' Mike Messer NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER CC Med-Waste. Systems, LLC (818) 998-5533 Lu F_ DATE MEDICAL WASTE COLLECTED oc 0 ADDRESS 2261 Palma Dr Unit 5 Ventura, CA 93003 05-06-2021 9:01 AM CLti z Bio 38 gallon Pharm waste = or c 2 gallon < oo� MA cont . oot e eoo r 2 25 1 2 t 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 CCI falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Q. 05-06-20219:01 AM a Evan Lieber NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) OF PERSO N S COLLECTIN G, TRANSPORTIN G OR UNLOADIN G WASTE INITIALS REGISTRATION NUMBER N Evan Lieber EL KCOMPANYNAME TELEPHONE NUMBER a (Stockton) Med-Waste Systems, LLC (818) 998-5533 Z DATE MEDICAL WASTE COLLECTED Q ADDRESS 4079 Cherokee Rd Stockton CA 95215 05-06-20219:54 AM Z Bio 38 gallon Pharm waste=or<2 gallon O o t r.e o0 ` , oat .r cont .. o0 e 2 25 1 2 I certify that the information provided above is true and correct and that only untreatedmedical wastes are contained in this load.) am aware that vQ~i M falsification of this. tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. E L� 05-06-202-19:54 AM Z Evan Lieber NAME OF COM PAN REPflESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE F COMPANYNAME TELEPHONE NUMBER F Healthwise Services (559) 834-3333 U ADDRESS < 4800 E Lincoln Ave Fowler CA 93625 ¢ PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED TSOST-89 05-07-2021 10:43 AM 27.00 Z DISCREPANCY INDICATION SPACE Q H H Z I certify that/ have been authorized to accept untreated medical wastes and that/ have received the above indicated wastes In accordance with the g requirements outlined In that authorization. (�� , ` 05-07-2021 10:43 AM w Carlos Gamez S (� I— NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency, call ( 818 ) 998-5533 (24 -hr company or other emergency response group telephone) ificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.