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Regulated Medical Waste TRACKING DOCUMENT 3088098 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 O 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, w packaged, labeled/placarded; and are in propel condition for transportation according to the applicable regulations of the Z U.S. Department of Transportation. Spencer Csakeu �`^"'" �" I 06-03-2021 9:27 AM N AM E OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAMES) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER or Med-Waste Systems, LLC (818) 998-5533 w it ADDRESS DATE MEDICAL WASTE COLLECTED 0 2261 Palma Dr Unit 5 Ventura, CA 93003 06-03-20219:27 AM on e o�c a nt a 0 0 I certify that the information provided above Is true and correct and that only untreated medical wastes are contained to this load./ 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. ¢ a Evan Lieber 06-03-2021 9:27 AM N AM E O F CO M PAN Y REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) O F PERSON S COLLECTIN G, TRAN SPORTIN G OR UN LO ADIN G WASTE INITIALS REGISTRATION NUMBER rV �C K COMPANY NAME TELEPHONE NUMBER O Q. Z DATE MEDICAL WASTE COLLECTED Q ADDRESS tt F- p#Co,v. 9cant Vag M.9 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 vQ~i or falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Z Z of NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE F COMPANY NAME TELEPHONE NUMBER } F- U ADDRESS Q PERMIT NUMBER DATEWASTEWAS DEPOSITED/UNLOADED TOTALWEIGHT DEPO SITED/UN LOADED w Z D15CREPANCY INDICATION SPACE Q K F- F Z Icerti(y that/ have been authorized to accept untreated medical wastes and that lhave received the above indicated wastes in accordance with the requirements outlined in that authorization. F- w H NAME O F COM PANY REPRESENTATIVE(Print) SIG NATURE OF REPRESENTATIVE DATE L17ncBseof 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.