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Regulated Medical Waste <br />TRACKING DOCUMENT# 3148550 <br />Certificate of Destr <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />2275 <br />n.o.s., 6.2, PGII <br />zx. a/j.,.aw soa w. <br />COMPANY NAMETELEPHONE <br />NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x 5513 <br />ADDRESS <br />or <br />O <br />23500 Kasson Rd Tracy, CA 95376 <br />F <br />I certify that the information provided is true <br />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 />U.S. Department of Transportation. <br />Mike Margullis <br />t �/� < asyv\ -"" 06-24-2021 8:57 AM <br />NAM E O F COMPAN Y REPRESENTATIVE(Print) <br />SIG NATURE O F REPRESENTATIVE DATE <br />NAMES) OF PERSON 5 COLLECTING, TRAN SPORTIN G <br />OR ON LOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />M <br />Med-Waste Systems, LLC <br />(8j 8) 998-5533 <br />¢ <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />O <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />06-24-20218:57 AM <br />0. <br />nL ..0 <br />ani. r <br />onL u <br />a <br />0 <br />H <br />y <br />I certify that the Information provided above is true and correct and that only unheated medial wastes are contained in [his load. I am aware that <br />falsification of this tracking document may result in <br />forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. <br />Q <br />d <br />Evan Lieber <br />06-24-20218:57 AM <br />N AM E O F CO M PAN Y REPRESEN TATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />TRANSFER STATION: NAME <br />REGISTRATION NUMBER <br />NAMRS) OF PER50NS COLLECTING, TRANSPORTINGOR <br />UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />rV <br />I <br />0C <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />0. <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />az <br />K <br />F <br />O <br />con r. <br />COnL <br />nont <br />Aonnt <br />1- <br />N <br />Icertify thatthe information provided above is true and correct and that onlyuntreated In wastes are contained in this load.l am aware that <br />falsification of this tracking document may result in <br />forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. <br />Z <br />s <br />NAME OF COMPANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />F <br />COMPANY NAMENUMBER <br />TELEPHONE <br />Healthwise Services <br />(559) 834-3333 <br />U <br />ADDRESS <br />< <br />4800 E Lincoln Ave Fowler CA 93625 <br />z <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL WEIGHT DEPOSITED/UNLOADED <br />LL <br />TSOST-89 <br />06-24-2021 12:36 PM <br />Z <br />DISCREPANCY INDICATION SPACE <br />Q <br />K <br />f - <br />F <br />Z <br />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 - <br />w2 <br />requirements outlined in that authorization. <br />F­ <br />1 <br />< <br />Kenny Ornellas <br />f y//I�/ 06-24-2021 12:36 PM <br />I�1Azra' <br />F- <br />N AM E O F COM PAN Y REPRESENTATIVE(Print) <br />SIG NATURE OF REPRESENTATIVE DATE <br />In <br />case of emergency, call ( 818 ) 998-5533 <br />(24 -hr company or other emergency response group telephone) <br />uction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations. <br />