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a <br />C <br />r <br />i <br />■�11MISTE EMEr" ROUTE NO. — <br />■l- <br />dw stem s om <br />Seq Generator No. 1 949-680002'4 <br />0 1• SUT.TER,nq. Y.; R' ING CT <br />YYVI.'.: <br />1530°Bess1e *109c <br />Tracy, CA 95376-3080 <br />2a. Description of Waste <br />Medical Wasle, NL?.S_, 6.2 <br />Regulated Medical Wasle,110,3., 6.2 <br />UN 3291, Poll <br />Regulated Medlcai ROS; 63 <br />. UNZIM11301 <br />Poll. - <br />MEDICAL WASTE TRACKING DOCUMENT <br />SERVICE DATE: 11/081201.1:':, .,. <br />SA204 TRUCK,NUMBER <br />24 -Hour Emergency Response <br />(800) 424-9300 <br />State Generator's ID No. <br />Generator's US EPA ID No. <br />2b. Container Type <br />SHARPS (Regulated Medlcal;Waste (Bio)) 0 gal <br />SHARPS (Phalmaceulical.Wa ) 0 gal <br />SHARPS (Regulated Medical Waste: (Bio)) 0 gals. <br />*�1ir-SE <br />JTransporter 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 />Transp_oFW 1 Acknowledgement of Receipt of Materials <br />Signature <br />g, I Transporter 2 Address: <br />2c. No <br />Applicable permit numbers: Escondido- 5868 — MW -172 qi "� «�qve . , <br />Phone #: (760) 489-5009 �.. <br />Vernon- 5688 — MW -157 A' e <br />Phone #: (323) 307-0514 a .tura T 55 1— <br />Print /Typed Name 111-7/017 Y � //�.S Date % ' Ates • _ '''�' � — <br />'iqtx <br />Phone #: ( ) <br />Signature Permit number: <br />Print/TvmW Name Date <br />_._I • Discrepancy <br />QTD terminated Pow TD # <br />...li, n.. 3. s m <br />7. Treatment Facility Printed Certification of Receipt and Treatment — a z <br />°I certify that the contents of the listed container/s have been received, treated c <br />and disposed of In accordance with all local, state, and federal regulations.' i3 j a E <br />Print Name <br />o <br />Signature <br />Ct <br />SO <br />N <br />qW <br />811A <br />Date Z <br />#x. <br />s: <br />�4c[c <br />•' <br />■_ <br />a � C <br />_ <br />x <br />J <br />i <br />Applicable permit numbers: Escondido- 5868 — MW -172 qi "� «�qve . , <br />Phone #: (760) 489-5009 �.. <br />Vernon- 5688 — MW -157 A' e <br />Phone #: (323) 307-0514 a .tura T 55 1— <br />Print /Typed Name 111-7/017 Y � //�.S Date % ' Ates • _ '''�' � — <br />'iqtx <br />Phone #: ( ) <br />Signature Permit number: <br />Print/TvmW Name Date <br />_._I • Discrepancy <br />QTD terminated Pow TD # <br />...li, n.. 3. s m <br />7. Treatment Facility Printed Certification of Receipt and Treatment — a z <br />°I certify that the contents of the listed container/s have been received, treated c <br />and disposed of In accordance with all local, state, and federal regulations.' i3 j a E <br />Print Name <br />o <br />Signature <br />Ct <br />SO <br />N <br />qW <br />811A <br />Date Z <br />