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MEDICAL WASTE TRACKING DOCUMENT <br />wwrns SERVICE DATE: 11/22/2011 <br />WASTE MAMAOEME111T <br />medwastemm.com ROUTE NO. SA204 TRUCK NUMBER <br />Seq Generator No. 24 -Flour Emergency Response <br />0 ,. SUTTER TRACY CONRMINITY (800) 424-9300 <br />HOSPITA <br />949-680001 Slate Generator's ID No. <br />1420 N Tracy Blvd <br />Tracy, CA 95376-3451 Generator's US EPA ID No. <br />2a. Description of Waste <br />Qi Regulated Medical Waste, N O.S., <br />UN 3291, PGII <br />Regulated Medical Wash, N.O.S., <br />UN 3291, PGII <br />armaceullcal Waste, <br />W PharmaceuhcaA W s* <br />w UN 3291, PGII <br />Wag, 11--g M8613rial%4abilw <br />UN 3291, PGII <br />Pharmaceutical VVasle <br />2b. Container Type 2c. No of <br />Containei <br />31 GALLON (Regulated Medical Chemotherapy Waste) 31 gal <br />31 GALLON (Regulated Medical Pathological Waste) 31 gal <br />31 GALLON (Pharmaceutical Waste) 31 gal <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 />Transporter 1 Acknowledgement of Revel zll <br />Signature <br />DocUMENT 0000442955 <br />Pem11t # TBS, Signature- <br />e <br />Ib. or 71B. Transfer Facility: <br />Volume WM Healthcare Solutions, Inc. <br />5337 Luce Avenue, BLDG 243G <br />McClellan, CA 95852 <br />Phone(512)356.8907 <br />Permit #: TS -98 <br />Signature <br />E 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 />7D, Autoclave Facility: <br />r Waste Management <br />1390 E Cornmerciai Row <br />Reno, NV 89512 <br />Phone (775) 326-2409 <br />Permit#: MSWL-003 <br />IWH-004 <br />TOTALS o�C� 7E. Transfer Facility: <br />Applicable permit number/s: Escondido- 5688 - MW -172 28 Healthcare Solutions, inc. <br />A <br />PP P 4280 Bandini Blvd. <br />Print/ Typed Name <br />5. J Transporter 2 Address: Smith Sys ms Tra portation Phone #: (800) 897-5571 <br />417 9"' Ave',111colisibluff, NE 69361 <br />P.O. Box 2455, Scottsbluff, NE 69363 <br />Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />Signature <br />Print/ Typed Name _ <br />6. Discrepancy <br />Comments <br />1-1 TD terminated New TD # <br />Permit number: <br />Date <br />Phone #: (760) 489-5009 Vernon, GA 90058 <br />Vernon- 5688 — MW -157 Phone (323) 307-0514 <br />Ph a #: (3 ) 307- 514 Permit #:TS/OST 81 <br />Signature <br />I -11WFete I a Date <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I certify that the contents of the listed container/s have been received, treated <br />and disposed of in accordance with all local, state, and federal regulations." <br />Print Name <br />Signature <br />Date <br />'n <br />a� <br />N <br />Em <br />O N b <br />C, o :: 0 <br />m a v <br />c <br />a -2 <br />o `m <br />U <br />c <br />�a <br />i <br />o <br />U � <br />N <br />° _ <br />U"' Y <br />O a <br />m O �y <br />0 <br />w c <br />m � ~ <br />2- <br />a <br />Eo c <br />.0 W O <br />c Z <br />m <br />N C N LL <br />r 0 9 L E <br />0 O c a <br />dm3 <br />U <br />� ac <br />d c y <br />a � <br />s m P o <br />d c <br />072 <br />FL <br />U <br />r <br />c <br />foo r <br />v o <br />0 <br />O`�� Wt <br />M uS CI?' <br />C(aE N <br />d o r <br />C9R� <br />E <br />