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g. <br />w <br />f., <br />MEDICAL WASTE TRACKING DOCUMENT <br />WVT\_�e SERVICE DATE: 11/01/2011 <br />W"TE MANAGEMENT ROUTE NO. — W04 TRUCK NUMBER <br />medwastemm.com <br />Seq Generator No. 1 949-680001 24 -Hour Emergency Response <br />0 1 • SUTTER TRACY CONWNITY (800) 424-9300 <br />HOSPITA State Generator's ID No. <br />949-680001 <br />1420 N Tracy Blvd <br />Tracy, CA 96376-3451 Generator's US EPA ID No. <br />2a. Description of Waste 2b. Container Type 2c. No of <br />Contalnel <br />Regulated Medical Waste, N.O.S., 6.2 31 GALLON (Regulated Medical Chemotherapy Waste) 31 gal <br />UN 3291, PGII <br />Regulated Medical Waste, N.O.S., 6.2 31 GALLON (Regulated Medical Pathological Waste) 31 gal <br />UN 3291, PGII <br />Pharmaceutical Waste <br />a <br />UN 3291, PGII <br />UN 3291, PGII <br />2t'=2rautlral UVA-A, <br />Pharmaceutical Waw <br />J Transporter 1 is to check box if this is a through shipment El <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transpc rter�Acknowledwmerit of Receipt of Materials <br />Signature <br />TOTALS IO=* <br />1111111111111111111 <br />Docuxfrv* . 0000442952 <br />Permit -': <br />Date <br />Ib. or 7S. Transfer Facility: <br />Volume WM Healthcare Solutions, inc. <br />6537 Loce Avenue, BLDG 243G <br />McClellan, GA 95652 <br />Phone (5121356-9907 <br />Permit #: TS -98 <br />Signature <br />Date <br />7C. incineration Facility: <br />WMRRRC <br />7505 State Hwy 65 <br />Anahuac, TX 77514 <br />Phone (409) 267-3913 <br />Permit #: MSW 2239-A <br />Applicable permit number/s: Escondido- 5688- MW -172 <br />Phone #:(760)489-5009 <br />Vernon- 5688 - MW -157 <br />Phone #: (323) 307J-/0514 <br />Print / Typed Name Ll�%` j� Date <br />❑ 7D. Autoclave Facility: <br />Waste Management <br />1390 E Commercial Row <br />Reno, NV 89512 <br />Phone (775) 326-2409 <br />Permit 4: MSWL-003 <br />IWW004 <br />7E. Transfer Facility: <br />WM Healthcare Solutions, Inc. <br />4280 Sand"avd. <br />Vemon, CA- X1058. <br />Fhone (32_)%Dti14 <br />Pe1111 #•TEST 81` ` <br />Sign <br />5. Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />N 417 9'" Ave, Scottsbluff, NE 69361 "1 certify that the contents of the listed container/s have been received, treated <br />d 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 />umberPrint / Typed Name Date <br />6 Discrepancy <br />Comments <br />FJTD terminated New TO # Signature Date <br />