COMPLIANCE INFO_2015-2021 - Laserfiche WebLink

Home Browse Search

Regulated Medical Waste TRACKING DOCUMENTp 3248523 {�, Certificate of Destruction; Med-Waste Systems, LLC certifies that CODE AREA UN3291, Regulated Medical Waste, 2275 n.o.s., 6.2, PGII 744 W 56564e«. 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, Of Z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the U.S. Department of Transportation. Mike Messer 07-29-2021 9:22 AM NAM E O F COM PANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE N AM DS) OF PERSON S'COLLECTING, THAN SPORTING O R ON LOADING WASTE INITIALS REGISTRATION NUMBER Evan Lieber EL 5039 COMPANY NAME TELEPHONE NUMBER Med-Waste Systems, LLC (818) 998-5533 Of ADDRESS DATE MEDICAL WASTE COLLECTED O 2261 Palma Dr Unit 5 Ventura, CA 93003 07-29-2021 9:22 AM a Z Bio 38 gallon Pharm waste= or < 2 gallon Chemo waste onr. 00� .e om. .. .e 4. 75 9 PO 2 2 H > I certify that the information provided above Is true and correct and that only untreated medical wastes are contained in this load.l am aware that m falsification of this tracking document may result in forfeiture of my transporters registration and/or the privilege of utilizing State -authorized facilities. a Evan Lieber 07-29-20219:22 AM N AM E OF COM PAN Y REPRESENTATIVE(Print) SIGNATURE O F REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER NAME(S) O F PERSO N S CO LLECTING, TRANSPORTIN G O R UNLOADING WASTE INITIALS REGISTRATION NUMBER N ,z WCOMPANY NAME TELEPHONE NUMBER O Z ¢ ADDRESS DATE MEDICAL WASTE COLLECTED (Y F- 2 O oor. a oot r on,. . nL .r oo� .w F I 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 falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State -authorized facilities. Lu Z Z NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER } F U ADDRESS ¢ PERMIT N UM DER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED Z DISCREPANCY INDICATION SPACE CCF - F Z Icertify that l have been authorized to accept untreated medical wastes and that) have received the above indicated wastes in accordance with the :E requirements outlined in that authorization. H w 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) he material listed above is treated in accordance with applicable local, state, and Federal regulations.