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VJ-LVAi MEDICAL WASTE TR LING DOCUMENT <br />SERVICE DATE: // <br />,2011 WASTE MANAGEMENT <br />imed aste.wmxom ROUTE No. - TRUCK NUMBER DOCUMENT <br />r, I soieis Sha art Ind r f a, = ro <br />Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit number/s: Escondido- 5688 — MW -172 4i4S T3eres� m <br />d 1996 Don Lee Place Ste. C Phone #: (760) 489-5009�b,CA 95725 �a <br />o _ Escondido, CA 92029 _ _ Vernon- 5688 — MW -157 <br />c Transporter 1 Acknowledgement of Receipt of Materials Phone #: (323) 307-0514 nattxr ST` m a <br />Ea <br />r m <br />Signature' Print / Typed Name Dateite��* a i° <br />5.1 Transporter 2 Address: <br />Signature <br />Print/ Typed Name <br />6. Discrepancy <br />Comments <br />TD terminated New TD # <br />Phone #: ( ) <br />Permit number: <br />Date <br />7. Treatment Facility Printed Certification of Receipt and Treatment - m m I <br />"I certify that the contents of the listed container/s have been received, treated c E l <br />and disposed of in accordance with all local, state, and federal regulations." 0 E <br />Print Name <br />Signature <br />Vo C d i <br />vl m <br />co c •. e <br />i •y r <br />M® N C 1 <br />o 0�3 <br />d <br />212 <br />c m E <br />(rycc <br />Date R <br />Seq <br />Generator No. <br />90001 <br />24 -Hour Emergency Responseta� <br />(800) 424-9300 <br />f�c <br />State Generator's ID No. <br />HOSPITA <br />1420 N Tracy BW <br />`I- 3 <br />Generator's US EPA ID No. <br />u <br />2a. Description of Waste <br />2b. Container Type <br />2c. No of <br />Containers <br />2d. Ib. or <br />Volume <br />,sypt �.2 <br />H,. ( I'm el blasts) gal - <br />„ <br />52.e.3! 4" y rill <br />Pe Ti t dMik at1� 51 N 0,.zt.; R2 <br />�; S $ h tach a. d E <br />� . F � � �� � l 0 <br />��� <br />UNI POO <br />t ,rm €ed e . a, a, -.: 0 3 ,1.7 <br />�a�t� � P(l' � t'�: c� ci I=�3 ) 0: i <br />�a <br />tu <br />hafm ubcol waste) a ar��iS�IIC <br />r�til�it �1l�Iii�r s <br />t.e"1t „3231, P100f?Fi�' <br />r a <br />l„a <br />��=% <br />4' <br />Transporter 1 is to check box if this is a through shipment El <br />TOTALS <br />Etestatlon Fablfity <br />r, I soieis Sha art Ind r f a, = ro <br />Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit number/s: Escondido- 5688 — MW -172 4i4S T3eres� m <br />d 1996 Don Lee Place Ste. C Phone #: (760) 489-5009�b,CA 95725 �a <br />o _ Escondido, CA 92029 _ _ Vernon- 5688 — MW -157 <br />c Transporter 1 Acknowledgement of Receipt of Materials Phone #: (323) 307-0514 nattxr ST` m a <br />Ea <br />r m <br />Signature' Print / Typed Name Dateite��* a i° <br />5.1 Transporter 2 Address: <br />Signature <br />Print/ Typed Name <br />6. Discrepancy <br />Comments <br />TD terminated New TD # <br />Phone #: ( ) <br />Permit number: <br />Date <br />7. Treatment Facility Printed Certification of Receipt and Treatment - m m I <br />"I certify that the contents of the listed container/s have been received, treated c E l <br />and disposed of in accordance with all local, state, and federal regulations." 0 E <br />Print Name <br />Signature <br />Vo C d i <br />vl m <br />co c •. e <br />i •y r <br />M® N C 1 <br />o 0�3 <br />d <br />212 <br />c m E <br />(rycc <br />Date R <br />