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Regulated Medical Waste TRACKING DOCUMENT# 3056201 Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and CODE AREA UN3291, Regulated Medical Waste, 2275 n.o.s., 6.2, PGII COMPANY NAME TELEPHONE NUMBER DVI-Deuel Vocational Institution (209) 835-4141 x 5513 ADDRESS O 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. �M - �^ 05-20-2021 8:57 AM Mike Messer t !"v N AVE O F COM PANY REPRESENTATIVE(Print) SIGNATURE O F REPRESENTATIVE DATE NAMES) 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 K ADDRESS DATE MEDICAL WASTE COLLECTED a 2261 Palma Dr Unit 5 Ventura, CA 93003 05-20-2021 8:57 AM zBlo 38 gallon ,. r one o� i Wt.® 9 COAL ® �� WILi 4 59 H y 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 ¢ document result In forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. falsification of this tracking may i of Evan Lieber 05-20-2021 8:57 AM a N AM E O F CO M PAN Y REPRESENTATIVE(Print) SIG N ATU RE O F REPRESEN TATIVE DATE TRANSFERSTATION: NAME REGISTRATION NUMBER NAME(S) O F PERSO N 5 CO LLECTIN G. TRAN SPORTING OR UN LOADIN G WASTE INITIALS REGISTRATION NUMBER N Lu iY COMPANY NAME TELEPHONE NUMBER O a Z ADDRESS GATE MEDICAL WASTE COLLECTED Q K F- O OOL ® O,. F 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 v¢~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. Z Cc NAME OF COM PAN REPRESENTATNE(Print) SIG NATURE OF REPRESENTATIVE DATE F- COMPANY NAME TELEPHONE NUMBER y H V ADDRESS Q PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTALWEIGHT DEPOSITED/UNLOADED Z Q DISCREPANCY INDICATION SPACE K H F Z 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 � requirements outlined in that authorization. E- Q � 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) tederal regulations.