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ACIN Regulated Medical Waste TRACKING DOCUMENT# 3050201 Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and reaeral regulations. 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 p 23500 Kasson Rd Tracy, CA 95376 F I certify that the information provided is true and correct, and that the generated materials are properly classified, described, Oc Lu packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the Z U.S. Department of Transportation. t0 �M �^ AM Mike Messer t t't�W 05-20-2021 8:57 NAME O F COM PAN Y REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S)OF PERSON 5 COLLECTIN G, TRANSPORTIN G OR ON LOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER Med-Waste Systems, LLC (818) 998-5533 W K DATE MEDICAL WASTE COLLECTED ADDRESS 2261 Palma Dr Unit 5 Ventura, CA 93003 05-20-2021 8:57 AM CL. Ln Z Bio 38 gallon ® °nt .w ont r f�oa , an,_ MA ¢ 4 53 I certify that the information provided above is true and correct and that onlyuntreated medical wastes are contained in this load. I am aware that y� falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilegeof utilizing State -authorized facilities. Z (/ a Evan Lieber 05-20-2021 8:57 AM N AM E O F C O M PAN Y REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) OF PERSON S COLLECTIN G, TRANSPO BEING O R UNLOADING WASTE INITIALS REGISTRATION NUMBER N r¢1 COMPANY NAME TELEPHONE NUMBER O Q. Z DATE MEDICAL WASTE COLLECTED Q ADDRESS 0C Zr Imn. n.a enont w ennnt..a 9 CQnL MIN NI 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 ¢ falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Z NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER Healthwise Services (559) 834-3333 U ADDRESS < 4800 E Lincoln Ave Fowler CA 93625 PERMIT NUMBER DATEWASTEWAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED TSOST-89 05-20-2021 12:42 PM 53.00 Z DISCREPANCYINDICATION SPACE Q f - H Z (certify that) have been authorized to accept untreated medical wastes and that l have received the above indicated wastes in accordance with the W � requirements outlined in that authorization. Rafael Carrillo -. �-- 05-20-2021 12:42 PM LJ � NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE r�lnase of emergency, call ( 818 ) 998-5533 (24 -hr company or other emergency response group telephone)