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V MEDICAL WASTE TF '(ING DOCUMENT <br />® SERVICE DATE: 10/1112011 <br />WASTE MANAGEMENT ROUTE NO. — W04 TRUCK NUMBER <br />m@dwaSte.Wm.com <br />Seq Generator No. 1 24 -Hour Emergency Response <br />1. (800) 424-9300 <br />HOSPITA State Generator's ID No. <br />1 <br />1420 N Tracy <br />Tracy, Generator's US EPA ID No. <br />2a. Description of Waste <br />,a <br />L Oil <br />Peguiated d; s is UO s., 6.2 <br />2b. Container Type <br />43 OSS (Regulated Medical Wate fBks)) 43 gal <br />J Transporter 1 Is to check box If this Is a through shipment FI <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />a� 1996 Don Lee Place Ste. C <br />_ _._.Escondido, CA 92029, <br />Transporter 1 Acknowledgement of Receipt of M#tet <br />N <br />e <br />t - <br />TOTALS TD=* <br />2C. No of ( 2d. Ib. or <br />Cnntalnarit Volume <br />Applicable permit numbers: Escondido- 5688 — MW -172 <br />Phone #: (760) 489-5009 <br />Vernon-5688_--MW-157._ <br />Phone #: (323) 307-0514 <br />Print/ Typed Name ,° ,r✓, =j / ` k Date ✓ <br />5, Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 1 7. ITreatment Facility Printed Certification of Receipt and Treatment <br />417 9"' Ave, Scottsbluff, NE 69361 °I certify that the contents of the listed container/s have been received, treated <br />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 />Signature Permit number:— <br />Print/ <br />umber:Print/ Typed Name Date <br />L Discrepancy <br />Comments <br />TD terminated New TD # <br />Signature <br />