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%STE MANAGEMENT <br />Jwaste.wmxa�m <br />Seq Gansu <br />W�0W TRACY 08GYN <br />90 580019 <br />1407 N Tracy e1wd <br />T" W, CA 96376,3445 <br />(209) 006-7313 <br />2a. Description Of —wasts <br />'6f <br />Merin ai V4iapq r. <br />R"OU, We a medkftal v1sa* fq"O� q, F, <br />MEDICAL WASTE T' XING DOCUMENT <br />SERVICE DATE: 1101v402011 <br />RoUTENO. — SAm TRUCK NUMBER <br />24 -Hour Emergency Response <br />(800) 424-9300 <br />State Generator's ID No. <br />2b. Container Type <br />BE= <br />L!J Transporter I Is to check box If this Is a through shipment <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA -92029 - <br />Tebrisportisr- I Acknowledgement Of1hecelptof Meter <br />Signature,. <br />S. Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />417 Ave, Scottsbluff, NE 69361 <br />V P.O. gth Box 2455, Scottsbluff, NE 69363 '1 certify that the contents of the listed contalner/s have been received, treated <br />C Intermediate Handier 2 Acknowledgement of Receipt Of Materials and disposed of in accordance with all local, state, and federal regulations." <br />, <br />C X <br />Signature Permit number: Print Name <br />Print/ Typed Name --- <br />Date <br />Discrepancy <br />E <br />E Comments <br />R8 <br />TD terminated Now TD # <br />Signature F7 <br />r <br />2c. No of 2d. <br />lb. or <br />0 E" Eys i <br />fCv, <br />V 61 vasm a 'gal <br />® <br />Volume <br />0 <br />C <br />iD <br />2v <br />0 <br />J <br />C <br />0 LM <br />C E 4L <br />V, <br />9D <br />< <br />E <br />2- up),co' " <br />I o <br />LO <br />< 00 Lo <br />gal <br />U) r- () 4 <br />co F� <br />W a0 (n <br />0 <br />U) <br />Z� 0 u - <br />El <br />TOTALS <br />1J'0E:::* <br />U. <br />Applicable permit number/s: Escondido. 5688 — MW -172 <br />C <br />0 <br />-Phone #: (760) 489-5009 <br />U) <br />Vernon- 5688 — MW -157E <br />2�1 <br />Phone #: (323) 307-0514 <br />W M r- OWL) <br />a z a v a a R <br />Print/ Typed Name <br />Date <br />S. Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />417 Ave, Scottsbluff, NE 69361 <br />V P.O. gth Box 2455, Scottsbluff, NE 69363 '1 certify that the contents of the listed contalner/s have been received, treated <br />C Intermediate Handier 2 Acknowledgement of Receipt Of Materials and disposed of in accordance with all local, state, and federal regulations." <br />, <br />C X <br />Signature Permit number: Print Name <br />Print/ Typed Name --- <br />Date <br />Discrepancy <br />E <br />E Comments <br />R8 <br />TD terminated Now TD # <br />Signature F7 <br />r <br />mm <br />& <br />0 E" Eys i <br />0 <br />C <br />iD <br />2v <br />0 <br />J <br />C <br />0 LM <br />C E 4L <br />V, <br />