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Ingenium DOC# <br /> 2255 Barham Drive Ste.A2151 <br /> Escondido,CA 92029 1 JIM <br /> Ph:800-805-6236 ® <br /> Fax:760-745-8786 1,,n Pr�f15.1�®91977} <br /> MEDICAL <br /> Generator/Address: LCon2l Hour Emergency Phone#: <br /> San Joaquin Delta College <br /> 5959 Pacific Ate ti 253 <br /> Stockton, CA' 95207 <br /> Transporter 1: tion: (If Applicable) <br /> Ingenium Group-LLC 2255 Barham Drive,Escondido,CA 92029A1l311tta <br /> DISC Hazardous Wasle Transporter Registration#4857 A 95035 <br /> 800-805-6236 75 f ti i'S-1 <br /> Designated Disposal transfer Facility: (Check One) <br /> ❑ Medical Waste HeallhWise ❑ Other: ❑ Other: ❑ Other. <br /> Services 4800 E Lincoln Ave. <br /> 7321 Quimby ST Fowler,CA 93625 <br /> Paramount,CA 90723 855-248-9473 Y <br /> 888.610-1311 Permit M TS89 <br /> Permit#:TS/OST94 <br /> Shipping Information: Treatment Code:Wricineration,M=Microwave,A-Auto roe <br /> Description Count Cont.Type I Est.WI A at Wt. Treatment New Tracking ID <br /> UN 3291,Regulated Medical Waste,6.2, Transfer Facility) <br /> PG If ERG#158 / <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG 11(Pathological Waste ERG#158 <br /> UN 3291,Regulated Medical Waste,6.2, <br /> PG II(Chemotherapy Waste ERG#158 <br /> Pharmaceutical Waste <br /> iiia <br /> This is to certify that the materials described _ove ry e roperly classified, packaged, marked and labeled and are in <br /> proper condition for transportation in aan,,- .W' applicable regulations of the United States Department of <br /> Transportation and the State of Califo f <br /> Generator: <br /> Na Signal <br /> In accordance with CA $iC 040-Tracking Records,generator t nsporting medical waste shall maintain its copy of the <br /> a shipping and tracking documents for three years. <br /> Trans orter 1: <br /> Nam®:(Print) Signature: Dale: <br /> Trar "fer tion 14 licable <br /> [ANd.(PrinQ-`q n Signature: Date: <br /> J�C t�, <br /> Tranftter 2: if Applicable) <br /> Name:(P(IffQ> Signature: Date: <br /> Desi nated Disposal/Transfer Facility <br /> Name:(Print) Signature: Date: <br />