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H <br />MEDICAL WASTE TRACKING DOCUMENT <br />WVTUF�a SERVICE DATE: 11/15/2011 <br />WAWM MANAGEMENT ROUTE NO. — TRUCK NUMBER DOCUMEN <br />madwontE!-watt-cnr� SA204 00004429,9 <br />Seq Generator No. 1 949-680001 <br />0 1' SUTTER TRACY COMMNITY <br />HOSPITA <br />949-6$0001 <br />1420 N Tracy Blvd <br />Tracy, CA 95376-3451 <br />2a. Description of <br />Regulated Medical Waste, N.O S. <br />Regulated MedicalV'Iaete, N.U.S., 6 <br />UN 3291, PGii <br />Pharmaceutical Wim, <br />PharrnaceuticalVAt*-, <br />Regulated MedicalWaste, N.O.S., 6 <br />UN 3251, PGiI <br />PGI, <br />Pharmaceutical Wa°1e <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 />31 GALLON (Regulated Medical Chemotherapy Waste) 31 gat <br />31 GALLON (Regulated Medical Pathological Waste) 31 gal <br />31 GALLON (Pharmaceutical Waste) 31 gal <br />43 GALLON (Regulated Medical Chemotherapy Waste) 43 gal <br />J Transporter 1 is tca check box if this is a through shipment <br />Transporter 1 Adetress: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of Receipt of Materials <br />2c. No of <br />7A. ? ransfer Facility: <br />WM Healthcare Solutions, Inc. <br />3670 Enterprise Ave, <br />Hayward, CA 94545 <br />Phone (s12j 356-8964, <br />56 89Qt� <br />Permit- -TS-96 <br />Signa <br />Date <br />ib. or i=i 7t3. Trainsiet' Facgr: <br />Volume WM Healthcare -Solutions; lhac <br />5337 Luce Avenue, MIX 243G <br />McClellan, CA, 05652 <br />Phone (572) 35OW7 <br />Permit #: TS -98 <br />Signature - <br />Date <br />7C. incineration Facility: <br />WMRRRC . <br />7505 State Hwy 65 <br />Anahuac TX 77514 <br />❑ 7D, Autoclave Facility: <br />Waste Management <br />1390 E Commercial Row <br />Reno, NV 89512 <br />Phone (775) 326-2409 <br />Permit #: MSWL-003 <br />5: 17fansporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />J 417 9`" 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 Handier 2 / Acknowledgement of Receipt of Materials Print Name <br />Signature <br />Print/ Typed Name <br />\ 6. Discrepancy <br />Comments <br />t3 <br />TD tetrminsted New TD # <br />Permit number: <br />Date <br />Slgnature <br />Date <br />LTOTALS ��� % <br />I <br />I <br />❑ 7E. Tran ster Facility: <br />Applicable permit numbers: Escondido- 5688 - MW -172 <br />PP p <br />28 Healthcare Solutions, Inc. <br />4280 Bandini Blvd. <br />Phone #: (760) 489-5009 <br />Vernon. CA 90058 <br />Vernon- 5688 — MW -157 <br />Phone (323) 307-0514 <br />Phone #: (323) 307-0514 <br />Permit#:TS/OST 81 <br />_ <br />//77 //-/� <br />� ` <br />Signature <br />Date <br />Print /Typed Name �J� Date <br />. <br />5: 17fansporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />J 417 9`" 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 Handier 2 / Acknowledgement of Receipt of Materials Print Name <br />Signature <br />Print/ Typed Name <br />\ 6. Discrepancy <br />Comments <br />t3 <br />TD tetrminsted New TD # <br />Permit number: <br />Date <br />Slgnature <br />Date <br />