COMPLIANCE INFO_2015-2021 - Laserfiche WebLink

Home Browse Search

Regulated Medical Waste TRACKING DOCUMENTM 3148550 Cert CODE AREA %n.o.s., UN3291, Regulated Medical Waste, 2275 6.2, PGII 74a,V540nvn 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 torted, 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 W U.S. Department of Transportation, LP Mike Margullis ��Q,,// ' �rV \ ( G KAA06-24-2021 8:57 AM NAME OF COMPANY 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 as Med-Waste Systems, LLC (818) 998-5533 it ADDRESS DATE MEDICAL WASTE COLLECTED a 2261 Palma Dr Unit Ventura, CA 93003 06-24-2021 8:57 AM z Z ¢ 4 cant.ons WJ 0 cant. MA 4 cant Wt.n 4 cant r 0 1 0 F 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 a falsification of this tracking document may result in forfeiture of my transporters registration and/or the privilege of utilizing State -authorized facilities. : I on Evan Lieber `' 06-24-2021 8:57 AM NAMEOFCOMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER N of W COMPANYNAME TELEPHONE NUMBER O w ZADDRESS DATE MEDICAL WASTE COLLECTED Q CC Z O ant .s onr. f om, a ,. .. ons .• F I certify that the information provided above Is true and correct and that only u ntreated 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 Q H NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER } F— U ADDRESS Q LL PERM IT NUM BER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED to Z Q DISCREPANCY INDICATION SPACE E- 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 W requirements outlined in that authorization. F 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) ificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.