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V- v® <br />WASTE MANAGEMENT <br />-1 --6 aurM w.. us% <br />DOCUMENTMEDICAL WASTE TF 'UNG <br />SERVICE DATE: -wvJ1112011 <br />e No. <br />DocuMENT #: <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 />Escondldo,.CA 92028 __ _ ___ _ __Vernon -5688_ -.MW -157 <br />Transporter 1 Acknowledgement of Receipt ofeMateroals Phone #: (323) 307-0514 <br />Signature <br />Print/ Typed Name <br />Date 1 `/ // <br />5, I Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />J 417 9th 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 <br />Print / Typed Name _ <br />6' Discrepancy <br />Comments <br />OTD terminated New TD # <br />Permit number: <br />Date <br />Signature <br />Date <br />Seq <br />Generato <br />MV0001 <br />24 -Hour Emergency Response <br />(800) 424-9300 <br />1 <br />HOSPITA <br />State Generator's ID No. <br />1 <br />1420 N Tracy SW <br />r <br />Generator's US EPA ID No. <br />(2001 -. 2-W 12 <br />2a. Description of Waste <br />2b. Container Type <br />2c. No of <br />Containers <br />2d. Ib. or <br />Volume <br />Regulaied MeftalWa*, RO.S , 6,2 <br />31 GALLON ( , . ul ,ai Chemotherapy ) 31 gal <br />t4 3m, prw <br />�,. <br />RegWatec e lr*l WmOa, tit.o.s., S-2 <br />31 GALLON (Regularl4d MedlCal P i teal 48SN) 31941 <br />Uri am, PG11 <br />I <br />W° <br />h rtr.e e #ts iV <br />w1 _ (P anY# ubc0l WWO) 3 1981 <br />2RequTmen <br />SP114741s V, <br />47q U- <br />t <br />x <br />wo <br />Al I <br />�1 <br /><sf3a <br />4' Transporter 1 Is to check box if this Is a through shipment TOTALS <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 />Escondldo,.CA 92028 __ _ ___ _ __Vernon -5688_ -.MW -157 <br />Transporter 1 Acknowledgement of Receipt ofeMateroals Phone #: (323) 307-0514 <br />Signature <br />Print/ Typed Name <br />Date 1 `/ // <br />5, I Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />J 417 9th 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 <br />Print / Typed Name _ <br />6' Discrepancy <br />Comments <br />OTD terminated New TD # <br />Permit number: <br />Date <br />Signature <br />Date <br />