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Regulated Medical Waste 2275 n.o.s., 6.2, PGII TRACKING DOCUMENTH 3128788 1 Certificate of 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 materia ls are properly classified, described, Z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the US. Department of Transportation. Spencer Osakeu �'I "�- `G7 06-17-2021 8:48 AM N AM E OF COM PANY 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 Q: Med-Waste Systems, LLC (818) 998-5533 ¢ ADDRESS DATE MEDICAL WASTE COLLECTED O 2261 Palma Dr Unit 5 Ventura, CA 93003 06-17-2021 8:48 AM a Z Bio 38 gallon Pharm waste = or < 2 gallon m. MA44 anc e ons. a m. s �� a cc 3 6 27 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 falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Q a Evan Lieber 06-17-2021 8:48 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 CO LLECTIN G, TRAM SPORTIN G OR UN LOADING WASTE INITIALS REGISTRATION NUMBER N W¢ ¢ COMPANYNAME TELEPHONE NUMBER O N Z ADDRESS DATE MEDICAL WASTE COLLECTED F- O ons. a onr. a cont. .e m canL F- 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 Q: 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 Q F NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER Y F J U ADDRESS Q PERM IT NUM BER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED W Z DISCREPANCY INDICATION SPACE Q 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. F - Q z � 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) Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.