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Regulated Medical Waste <br />TRACKINGDOCUMENTit 3350689 <br />Certificate of Destruction; Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local; state, and federal regulations. <br />CODE AREA <br />UN3291, Regulated Medical Waste, <br />2275 <br />WASTE <br />SEMS <br />n.o.s., 6.2, PGII <br />COMPANY NAME <br />TELEPHONE NUMBER <br />DVI-Deuel Vocational Institution <br />(209) 835-4141 x 5513 <br />ADDRESS <br />O <br />23500 Kasson Rd Tracy, CA 95376 <br />� <br />I certify that the inform ation 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 />L. McGhee <br />�/d1/��� <br />— - `" 09-02-2021 9:39 AM <br />N AME O F COM PANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />NAME(S)OF PERSONS COLLECTING, TRANSPORTING <br />OR UNLOADING WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />Evan Lieber <br />EL <br />5039 <br />COMPANY NAME <br />TELEPHONE NUMBER <br />Med-Waste Systems, LLC <br />(818) 998-5533 <br />W <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />0 <br />2261 Palma Dr Unit 5 Ventura, CA 93003 <br />09-02-2021 9:39 AM <br />Z <br />Bio 38 gallon <br />ant .a4 T <br />nt. .. <br />ont. M.9 <br />L wt# <br />lcoot <br />t <br />y <br />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 <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 />X <br />Evan Lieber <br />`' 09-02-20219:39 AM <br />N AME O F COM PANY REPRESENTATIVE(Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />TRANSFERSTATION: NAME <br />REGISTRATION NUMBER <br />N <br />N AM E(S) OF PERSONS CO ELECTING, TRAN SPO RTING <br />O R UNLOADIN G WASTE <br />INITIALS <br />REGISTRATION NUMBER <br />COMPANY NAME <br />TELEPHONE NUMBER <br />O <br />a <br />Z <br />Q <br />ADDRESS <br />DATE MEDICAL WASTE COLLECTED <br />X <br />F - <br />Z <br />O <br />4 conL MA <br />Fa canL M.4 <br />4 C*nt M. <br />U cant <br />sconL <br />F- <br />NI <br />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 <br />W <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 />Q <br />F <br />NAME OF COMPANY REPRESENTATIVE (Print) <br />SIGNATURE OF REPRESENTATIVE DATE <br />COMPANY NAME <br />TELEPHONE NUMBER <br />} <br />H <br />J <br />U <br />ADDRESS <br />Q <br />W <br />PERMIT NUMBER <br />DATE WASTE WAS DEPOSITED/UNLOADED <br />TOTAL W EIGHT DEPO SITED/UNLOADED <br />Z <br />Q <br />DISCREPANCY INDICATION SPACE <br />I— <br />H <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 />g <br />requirements outlined in that authorization. <br />H <br />Q <br />� <br />NAME OF COMPANY REPRESENTATIVE (PrinO <br />SIGNATURE OF REPRESENTATIVE GATE <br />In <br />case of emergency, call ( 8188 998-5533 <br />(24 -hr company or other emergency response group telephone) <br />