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Al <br />in <br />Seq <br />JAV-16,e <br />Generator No. 1 949-580019 <br />1.SGhF TRACY OBGYN <br />949-580019 <br />1407 N Tracy <br />Traoy, CA 96376-3446 <br />7313 <br />2a. Description of Waste I 2b. Container Type <br />i� ��I li �rli5 <br />..111.1 <br />DOCUMENTMEDICAL WASTE TF (INo <br />SERVICE DATE: 10/04,12011 <br />W" TRUCK NUMBER <br />24-Mour Emergency <br />1 424-9300 <br />State Generator's ■ <br />Medical W )) 31 gm <br />2c. No of <br />4. u Transporter 1 Is to check box If this Is a through shipment a ( TOTALS 11= > I Y <br />Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit numbers: Escondido- 5688 - MW -172 <br />1996 Don Lee Place Ste. C Phone #: (760) 489-5009 <br />Escondido, CA_92029 Vernon- 5688---MW-157 <br />Transporter 1 Acknowledgement=f Receipt of Materials Phone #x`(323) 307-0514 <br />~ Signature r, Print/ Typed Name Date <br />DOCUMENT X <br />Ki <br />5. Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />` 417 9th Ave, Scottsbluff, NE 69381 "I certify that the contents of the listed container/s have been received, treated <br />2 P.O. Box 2455, Scottsbluff, NE 69363 and disposed of In accordance with all local, state, and federal regulations." <br />Intermediate Handler 2 / Acknowledgement of Receipt of Materials Print Name <br />c = Signature Permit number: <br />~ e <br />Print/ Typed Name Date <br />6. <br />Discrepancy <br />Comments <br />EITD terminated New TD # Signature Date <br />