Laserfiche WebLink
A Regulated Medical Waste <br />TRACKING DOCUMENTM 3128788 <br />Certificate of <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />T <br />2275 <br />n.o.s., 6.2, PGII <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x 5513 <br />ADDRESS <br />O <br />23500 Kasson Rd Tracy, CA 95376 <br />I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br />Z <br />packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br />� <br />U.S. Department of Transportation. <br />^� <br />`LAY-/��s <br />Spencer Osakeu � 06-17-2021 8:48 AM <br />N AM E OF COM PANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br />N AM Fist OF PERSONS COLLECTIN G, TRANSPORTING OR ON LOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Q: <br />Med-Waste Systems, LLC <br />(818) 998-5533 <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />O <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />06-17-2021 8:48 AM <br />a <br />Z <br />Bio 38 gallon <br />Pharm waste.= or < 2 gallon <br />om. c. <br />one s <br />one .. <br />nL <br />oc <br />3 44 <br />6 27 <br />F <br />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 <br />CCQ <br />falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. <br />a <br />Evan Lieber 06-17-2021 8:48 AM <br />NAME OF COMPANY REPRESENTATIVE(Print) SIG N ATLI R E O F REPRESEN TATIVE DATE <br />TRANSFER STATIONT NAME <br />REGISTRATION NUMBER <br />NAMES) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />N <br />C <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />Q <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />ca <br />F- <br />O <br />ont. .s <br />I cont. M.8 <br />scom WA <br />Xwnt r <br />4wnt. <br />F <br />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 <br />v¢~i <br />falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. <br />w <br />N <br />Z <br />E- <br />NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Y <br />1- <br />Healthwise Services <br />(559) 834-3333 <br />J <br />V <br />ADDRESS <br />< <br />4800 E Lincoln Ave Fowler CA 93625 <br />Oc <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />TSOST-89 <br />06-17-202112:21 PM <br />71.00 <br />Z <br />DISCREPANCY INDICATION SPACE <br />Q <br />K <br />H <br />F <br />Z <br />i certifythat I have been authorized to accept untreated medical wasteland that I have received the above indicated wastes in accordance with the <br />�j <br />requirements outlined in that authorization. <br />~ <br />w <br />Sergio Segura C// 06-17-2021 12:21 PM <br />F <br />NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br />In case ofemergency, call( 818 ) 998-5533 (24 -hr company or other emergency response group telephone) <br />Destruction: Med-Waste Systems; LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations. <br />