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Regulated Medical Waste 2275 n.o.s., 6.2, PGII TRACKING DOCUMENT 3168682 Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations. CODE AREA UN3291, Regulated Medical Waste, 2275 n.o.s., 6.2, PGII 716 COMPANYNAME TELEPHONE NUMBER DVI-Deuel Vocational Institution (209) 835-4141 x 5513 ADDRESS O 23500 Kasson Rd Tracy, CA 95376 1 certify that the information provided is true and correct, 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 U.S. Department of Transportation. � 0� n C7' "\r' 07-01-2021 8:58 AM Mike Margullis NAM E O F COM PAN Y REPRESENTATIVE(Print) SIGNATURE O F REPRESENTATIVE DATE NAME(S) OF PERSON 5 CO LLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER Med-Waste Systems, LLC (818) 998-5533 ADDRESS DATE MEDICAL WASTE COLLECTED 2261 Palma Dr Unit 5 Ventura, CA 93003 07-01-2021 8:58 AM Z ont0 .r nnc a ant ® nr. a om. e 0 I certify that the information provided above is true and correctand that only untreated medical wastes are contained in this load. I am aware that � falsification ofthis tracking document may result in forfeiture of mytransporter's registration and/or the privilege of utilizing State -authorized facilities. a Evan Lieber 1, v 07-01-20218:58 AM NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) O F PERSO N S COLLECTING, TRANSPORTIN G O R ON LOADING WASTE INITIALS REGISTRATION NUMBER N tr W ¢ COMPANY NAME TELEPHONE NUMBER O Z ADDRESS DATE MEDICAL WASTE COLLECTED K F- O ,. ,.,[ wa. .r ons. .r rn .m ani. .n r, .rz am .+. nt a a, .n. cont. e F NI certify that the information provided above is true and correct and that onlyuntreated medical wastes are contained in this load. I am aware that w falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Z F- NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER } H V ADDRESS Q w PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED Z DISCREPANCY INDICATION SPACE Q F— ZI certify that I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the Lu requirements outlined in that authorization. H Lu Lu E_ NAME OF COMPANY REPRESENTATIVE (Print) SIG NATURE OF REPRESENTATIVE DATE In case ofemergency, call( 818 )998-5533 (24-hrcompany or other emergency response group telephone) Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.