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H <br />MEDICAL WASTE TRACKING DOCUMENT <br />IFJ7�lza SERVICE DATE: 11/22/2011 !i <br />WASTE MAIYACIE S IVT <br />0-, ROUTE No. — sAm TRUCK NUMBER DOCUMENT :0000488296 <br />rMe�lvrr�e�a wrw wnrn <br />Seq Generator No. 1949-680001 <br />1 SUTTER TRACY &AGING GTR <br />949-880002 <br />1530 Bessie Ave #109 <br />Tracy, CA 95376-3080 <br />2a. Description of Waste <br />Regulated MedicalVVB-Ne,14O.S., b.2 <br />UN 3291, PGH <br />Regulated Medical Waw, tLU.S , 6.2 <br />UN 3211, PGII <br />Regulated Metllcal Wade, N U.S., b.2 <br />UN 3291, PGII <br />Regulated Medical Wasle, N.O.S., 6.2 <br />UN 3291, PGH <br />ON 3291, PiiH <br />PGI; <br />lJN 3291, PGII <br />NGI1 <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 Medical Waste (Bio)) 0 gal <br />SHARPS (Pharmaceutical Waste) 0 gal <br />SHARPS (Regulated Medical Waste (Bio)j al <br />J Transporter 1 is to check box if this Is a through shipment <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of RI-plaWt-"atei <br />Signature <br />2c. No of <br />V <br />❑ (TOTALS =* <br />Applicable permit number/s: Escondido- 5688 -W-172 <br />Phone #:(760)489-5009 <br />Verno9oZ688 - W-157 <br />( Phone #•(323)307-0514 <br />Print / Typed Name V-tw I ice% Iq <br />mo > <br />I a 2 9 I I( Date a to <br />[-17A. Transfer Facility: <br />E --1 <br />WM Healthcare Solutions, Inc. <br />'9 certify that the contents of the listed container/s have been received, treated <br />3670 Enterprise Ave. <br />and disposed of in accordance with all local, state, and federal regulations." <br />o E c <br />Hayward, GA 94545 <br />o m <br />= 0X <br />Phone(512)356-8901 <br />L <br />m <br />Permit number: <br />Permit #: TS -96 <br />Signature-_ <br />$ ' J <br />c <br />6. <br />Y�T•e <br />CLO <br />r 3 <br />M <br />V <br />Ib. or <br />L_"i 78. Transfer Facility: <br />a o <br />e <br />me <br />WM Healthcare Solutions, Inc. <br />d � <br />o <br />m <br />OV <br />5337 Luce Avenue, SLOG 243G <br />m <br />McClellan, CA 95652 <br />-0 3 <br />rn <br />n <br />Phone (512) 356.8907— <br />Permit 0: TS -98 <br />y a 1 <br />Signature <br />$ = J <br />a <br />Date <br />m C <br />7C. Incineration Facility: <br />o <br />WMRRRC <br />c =o <br />w <br />7505 State Hwy 65 <br />Anahuac, TX 77514 <br />r c 1 <br />8 v <br />~ <br />Phone (409) 267-3913 <br />m <br />Permit #: MSW 2239-A <br />ro `m <br />"� <br />E] 7D. Alternate Facility: <br />COL = <br />E L9 E <br />to=N <br />Z- <br />6 O � rn <br />m <br />m ' pf <br />►+ LL <br />7E. Destination Facility: <br />' ti <br />= vCL <br />Daniels Sharpsmart, Inc. <br />®f° W <br />I <br />4144 E Therese Ave. <br />= m c <br />~ <br />Fresno,93725 <br />0 <br />34-6 <br />Phone (555 9) 834-6252. <br />m 0 v <br />Permit #i TS/OST 55 <br />Si nature <br />� <br />— <br />mo > <br />I a 2 9 I I( Date a to <br />�10E <br />� E m <br />vm� <br />ca <br />Lamm <br />V ai <br />JON - <br />5 <br />r 2 � <br />L U 0 <br />d � m <br />m <br />0 W a <br />21 <br />- <br />r <br />7• Treatment Facility Printed Certification of Receipt and Treatment <br />5. Transporter 2 Address: Phone #: ( ) <br />'9 certify that the contents of the listed container/s have been received, treated <br />m` <br />and disposed of in accordance with all local, state, and federal regulations." <br />o E c <br />Print Name <br />= 0X <br />FSignature <br />Permit number: <br />Print / Typed Name Date <br />6. <br />Discrepancy <br />M <br />E <br />yc <br />Comments <br />OV <br />TD terminated New TD # <br />Signature Date <br />�10E <br />� E m <br />vm� <br />ca <br />Lamm <br />V ai <br />JON - <br />5 <br />r 2 � <br />L U 0 <br />d � m <br />m <br />0 W a <br />21 <br />