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MEDICAL WASTE TRACKING DOCUMENT <br />wwrns SERVICE DATE:WASTE j 1/Q$1201 <br />m® astemm®com 1RouTE No. - � TRUCK MUMSER <br />Seq Generator No. 949-8$0002 24 -Hour Emergency Response <br />0 ,. S Y ING CTR , (900) 424-9300 <br />940-680002 � State Generator's ID No. <br />1530 Bessie #109 <br />T CA 95378-3080 <br />' Generator's US EPA ID No. <br />2a. Description of Waste 2b. Container Type ac. No of <br />contamej <br />Regulated Medical Waste, N.O.S., 6.2 31 GALLON (Regulated Medical Waste (Blo)) 31 gal . <br />UN 3251, PGH . <br />:��e7 <br />Regulated Medical Waft N.O.S., 6.2 43 GALLON (Regulated Medical Waste (Blo)) 43 gal <br />UN 3251, PGH <br />J Transporter 1 Is to check box R this Is a through shipment Q <br />L Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Trans 1 Acknowledgement of Receipt of Materials <br />~ Slgnaturet <br />TOTALS OBE::* <br />It * I t 1.1 <br />i' <br />.x . <br />Applicable permit numbers: Escondido- 5688 — MW -172, <br />Phone #: (760) 489-5 <br />Vernon- 5688 — MW -157 <br />Phone #: (323) 307-8514 <br />Prird / Typed dame r� � � Date //—g-// <br />J TraKporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />417 a Ave, Scottsbluff, HE 69361 °1 certify that the contents of the listed container/s have been received, treated <br />P.O. Box 2455, Scottsbluff, HE 69363 and disposance with III i�nd federal reguiatlom' <br />Intermediate Handier 2 / Acknowledgement of Receipt of Materials Print Name IT" <br />Signature <br />Print / Typad Neme <br />6. Discrepancy <br />Comments <br />11 TD terminated New TD M <br />Permit number: <br />Date <br />Date [I. <br />11 ) 1 <br />