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Ingenium <br /> 2255 Barham Drive Ste.A DOC# <br /> Escondido,CA 92029 <br /> Ph:800-805-6236 <br /> Fax:760-745-8786Y-'-weniu �� <br /> . Pr13yl:L&Tb1 rTJt) <br /> MEDICAL WASTE DOCUMENT <br /> Generator/Address: Contact/24 Hour Emergency Phone#: <br /> St1tl !dt �.�Ite� �. <br /> 5161 Pacific,Aw 60"n=3 <br /> 3 <br /> Stacktoo, CA !�xioj <br /> FPermit <br /> orter 1: Transfer Station: (If Applicable) <br /> Group-LLC t ti <br /> rham Drive,Escondido,CA 92029 �,Avows <br /> azardous Waste Transporter Registration#4857 tom, C W <br /> -6236 ,l'SA} <br /> ated Disposal/Transfer Facility: (Check one) <br /> 1 <br /> ical Waste HeallhtNlse ❑ Olher. ❑ Other.ices 4800 E Lincoln Ave. ❑ Other: <br /> Quimby ST Fowler,CA 93625 <br /> mount,CA 90723 855-248-9473 <br /> 610-1311 Permit#:TS89 <br /> it#:TS/OST94 <br /> Shi in Information: Treatment Code:Mricineration,M=Microwave,A-Auto ve <br /> Description Co unl Cont.Type Est.Wt. A at W1. Treatment New Tracking ID <br /> UN 3291,Regulated Medical Waste,6.2, Transfer Facili <br /> PG If ERG#158 <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG 11 Palhot ical Waste ERG#158 <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG II(Chemotherapy Waste ERG#158 <br /> Pharmaceutical Waste <br /> i <br /> This is to certify that the materials describ • ve a eNy classified, packaged, marked and labeled and are in <br /> proper Transportation <br /> for transportation Ina cele f applicable regulations of the United States Department of <br /> Transportation and the State of @'dlifo <br /> Generator: <br /> Na �J . / r t � `� Signal r :... r site•,_ I <br /> In accordance with C & D4? _Tracking Records,generator t nsporting medical waste shall maintain its copy of the f <br /> shipping and tracking documents for three years. <br /> Transporter 1: i1h, <br /> i <br /> Name:{Pri t) �'� Signature: � <br /> TrApsf r S 't'bn: IfA livable)r { <br /> e. Print Signature: <br /> € lt� C14L/. ,Gcl d0, Date: - <br /> /d <br /> Trans orfs if A livable <br /> Name.(( rl Signature: <br /> Date: i <br /> Designated Disposal/Transfer Facility <br /> Name:(Print) Signature: ii <br /> Date: <br />