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MEDICAL WASTE TRACKING DOCUMENT <br />® SERVICE DATE: 11/22/2011 <br />WASTE MAItYACIEMENT <br />medwastemm.com ROUTE NO. — SA204 TRUCK NUMBER <br />Seq Generator No. "g-680001 24 -Hour Emergency Response <br />0 1' SUTTER TRACY COIVMNITY (800) 424-9300 <br />HOSPITA State Generator's ID No. <br />949-080001 <br />1420 N Tracy Blvd <br />Tracy, CA 95376-3451 Generator's US EPA ID Na. <br />I2a. Description of Waste <br />Regulated Medical UVasip N.O.S., 6 <br />O UN 3291, PGII <br />Regulated#tedlcalVVaste,N.O.S.,6 <br />UN 3291, PGiI <br />Z <br />V <br />r <br />°a <br />C <br />w <br />I- <br />2b. Container Type <br />31 GALLON (Regulated Medical Wasce (610)) 31981 <br />43 GALLON (Regulated Medical Waste (810)) 43 <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 o_ fRecet_.� A laiel <br />Signature <br />11Q11,1111 11,111111111111 <br />DOCUMENT 0000442930 <br />.tore <br />2c. No of 2d. Ib. or 2`713. Transfer Facility: <br />Containers Volume WM Healthcare Solutions, Inc, <br />W37 Luce Avenue: BLDG 243E <br />McClellan, CA 95652 <br />Phone(512)356-8907 <br />Permitil: TS -98 <br />Signature <br />Date <br />Q 7C. incineration Facility: <br />WMRRRC <br />7505 State Hwy 65 <br />Anahuac.TX 77514 <br />Phone (409) 267-3913 <br />Perrrfit# MSW 2239-A <br />7D: Autoclave Facility: <br />El I TOTALS M=> <br />Applicable permit number/s: Escondido- 5688 - MW -172 <br />Phone #:(760)489-5009 <br />Vernon- 5688 - MW -157 <br />(323) 307-0514 <br />Print/ Typed Name I Y •J <br />�711 <br />Date 1 )A, <br />1390`1=Commercial Row <br />Reno, NV 69512 <br />Phone (775) 326-2409' <br />Permit#: MSWL-003 <br />IWH-004 <br />7E. Transfer Facility <br />WM Healthcare Solutions Inc. <br />4280 Bandinl Blvd. <br />Vernon, CA 90058 <br />Phone (323) 307-0514 <br />Permit #:TS/OST,81 <br />Signature <br />Date <br />5, Transporter 2 Address: Smith S s Transportation Phone #: (800) 897-5571 7. Treatment Facility Printed Certification of Receipt and Treatment <br />-- 417 gfh Ave, Scottsbluff, NE 69361 "1 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 Handler 2 / Acknowledgement of Receipt of Materials Print Name <br />Signature <br />Print / Typed Name <br />J Discrepancy <br />Permit number: <br />Date <br />Comments F- <br />aTD terminated New TD # <br />Signature <br />Date <br />tcL <br />N <br />Q cu <br />a <br />CL <br />E <br />0 <br />s G a <br />a �m e <br />a `0 f9 <br />a m u <br />o� <br />r <br />d <br />S <br />o m <br />d � <br />c <br />cy <br />ro, m <br />E <br />m3 1 <br />R 8 <br />y o �+ <br />is o <br />c W Z 0 <br />o <br />rn <br />mU <br />N `7 <br />LL <br />o c m <br />c d a C <br />m <br />m a m <br />ram � <br />m , <br />� c, o <br />_e a �- <br />�' me } <br />a . c <br />a,-� CC <br />L N m O <br />C � v <br />Cc <br />y C <br />� am <br />Uoc w IL <br />li <br />y w c 3 m <br />L 'y ld B r <br />0 m ° C <br />m c ar3 <br />C E to <br />0-0.2 <br />y <br />(f,yc <br />