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24-Hour Emergency Phone Tracking Document Number: <br /> ♦=:/ra, Number: 888-785-7225 <br /> ` D197435 <br /> ACT` <br /> Medical Waste Tracking Document <br /> enuiro <br /> o Facility Name: Name: <br /> ecooet.( anteGF KiibQtley 1ili1Iight <br /> W 450 E.Yosemite Ave <br /> WE Address: Phone:Mardecat (%A 95-1-11; 209-558-0860 <br /> Shipping Description(s) #of Cont. Cont. Size Estimated Actual *-treatment <br /> Type Weight Weight <br /> UN 3291, Regulated Medical Waste, N.O.S. <br /> 6.2,PG II <br /> UN 3291,Regulated Medical Waste, N.O.S. <br /> 6-2,PG II (Pathological Waste) `� �/r J I `� e4 <br /> UN 3291, Regulated Medical Waste, N.O.S. <br /> 0 6.2, PG Il (Chemotherapy Waste) <br /> L6 <br /> z <br /> 2 Non-Hazardous Pharmaceutical Waste <br /> EL <br /> a_ <br /> x <br /> Nan-Regulated <br /> Other(specify): <br /> 'A =Autoclave, I=Incineration, M=Microwave <br /> Advanced Chemical Transport,Inc. CA Hazardous Waste Registration:4026 <br /> 1210 Elko Drive,Sunnyvale,CA 94D89 EPA ID#:CAR000070540 <br /> w <br /> Z Motor Carrier Permit:0194741 <br /> 0 <br /> E] 1210 Elko Drive El2010 Mission Ave. 265 Riggs Avenue ❑ 13722 Carmenita Road <br /> 0 Ir Sunnyvale,CA 94089 Escondido,CA 92029 Merced,CA 95341 Santa Fe Springs,CA 90670 <br /> 408-548-5050 760-489-5600 209-722-4228 714-545-2191 <br /> ~z MWTS Permit#TS-42II MWTS P it#/;-1 40 MWTS Permit#TS-8 <br /> Print Name: o rv1Gv 9j.Signature. e::�� Date: <br /> Name: DOT#: <br /> 0 <br /> W Address: State Transporter#or Permit: <br /> Print Name: Signature: Date: <br /> Z I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> a O marked and labeled,and are in all respects in proper condition for transport according to applicable governmental regulations. I certify that this shipment does <br /> a not contain regulated hazardous and or radioactive waste. lam aware that there are significant penalties for submitting false information including the possibility <br /> of fines and imprisonment. <br /> tai rr l <br /> g ]1/^ lKIl 1 A l ,, 6 <br /> 5i nature: J` j h �- /� Print Name: N i Dater <br /> I - <br /> Advanced Chemical Transport ACT Medical Advanced Chenicat Transport Advanced Chemical Transport <br /> 1210 Elko Drive 2010 Mission Ave. 265 Riggs Avenue 13722 Ca nenim Road, <br /> ur a Sunnyvale,GA 94089 Escondido,CA 92029 Merced,CA 95341 <br /> N 406-548-5050 760-89.5600 209-722-4226 Ii�71�}�70 <br /> q MIMrS Perm t#TS-42 Permit#TVOST-66 MWTS Permlt#TS500 MWTS Permit#TS-$ <br /> THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE TRANSFER FACILITY CHECKED ABOVE. Signature 8r date: <br /> ❑ ACT MedicalHealthvrise Services Medical 13Waste Management Healthcare Other <br /> z 2040 Mission Road Waste Disposal solutions, <br /> 2 Escondido,CA 92029 4800 E.Lincoln Ave 4280 Bandini Blvd r <br /> 76069-5600 Fowler,CA 93625 Vernon,CA 90058 <br /> Z_j Permit#TVDST-66 559-834-3333 323-307-0514 <br /> Fy g Pennit#TS,39 PerrN[#TS=T-81 <br /> W LL <br /> THIS IS TO CERTIFY THAT THE WASTE IDENTIFIED ABOVE WAS <br /> RECEIVED AT THE DESTINATION FACILITY CHECKED ABOVE. Signature&Date: <br />