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Regulated Medical Waste 2275 n.o.s., 6.2, PGII TRACKING DOCUMENT# 3186772 l Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal 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 materials are properly classified, described, u' packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the Z U.S. Department of Transportation. �(V� (�,f/�1p ,� Mike Messer 6�� Y,,,, " "" " , 07-08-2021 9:11 AM N AME OF CO MPAN Y REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAMES) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER w Med-Waste Systems, LLC (818) 998-5533 ¢ ADDRESS DATE MEDICAL WASTE COLLECTED 0 2261 Palma Dr Unit 5 Ventura, CA 93003 07-08-20219:11 AM Z Bio 38 gallonPharm waste=or<2 gallon om. c® oor a om. ® m. a gni .r 2 38 2 11 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 z falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Q �i / L a Evan Lieber 07-08-2021 9:11 AM NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAMES) OF PERSO N S CO LLECTING, TRANSPORTIN G OR UN LOADIN G WASTE INITIALS REGISTRATION NUMBER N z K COMPANYNAME TELEPHONE NUMBER O a aZ K ADDRESS DATE MEDICAL WASTE COLLECTED H Z OA coat M.1 M.e 4 Cana. . Itont Wt# gtoflL MA f- I certifythatthe information provided above lstrueandcorrectand that only untreated medical wastesare contained in this load. l am awarethat v¢~i ¢ falsification ofthis tracking documentmayresultin forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Z QZ F NAME OF COMPANY REPRESENTATIVE (Print) SIG N ATURE O F REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER >- F- U ADDRESS Q PERM IT N UM BER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL W EIG HT DEPO SITED/UNLOADED Z Q DISCREPANCY INDICATION SPACE K F F Z I certify [hat 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- Q z F' NAME OF COMPANY REPRESENTATIVE (Print) SIG NATURE OF REPRESENTATIVE DATE In case of emergency, call ( 818 ) 998-5533 (24 -hr company or other emergency response group telephone) regulations.