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MEDICAL WASTE TRACKING DOCUMENT
<br />wwrne SERVICE DATE: 11/29/2011
<br />YUAME MANAGEMENT ROUTE NO. — X04 TRUCK NUMBER
<br />medwastemm.com
<br />Seq Generator No. I 94y -X80001 24 -Hour Emergency Response
<br />0 1 SUTTER TRACY COMWNiTY (800) 424-9300
<br />HOSPITA State Generator's ID No.
<br />949-0E0001
<br />1420 N Tracy Blvd
<br />Tracy, CA 95376-3451 Generator's US EPA ID No.
<br />DocuMEP 0000442931
<br />2a. Description of Waste 2b. Container Type 12c. No r..,�►.tof
<br />�,a.a I za. Ib. or L
<br />Volume
<br />Regulated Med+caiWa5te,N.U.S., 6.2 31 GALLON (Regulated Medical Waste (Bic)) 31 gal
<br />O UN 3291, PGII
<br />RegulatedMedicalWast,:N.O.S, 6.2 O gulated MedicalWaste (Sio)) 43 gal
<br />UN 3291, PGIi
<br />OQ
<br />W
<br />t9
<br />J Transporter 1 is to check box if this is a through shipment
<br />c�
<br />E
<br />c8
<br />Transporter 1 Address: WM Healthcare Solutions, Inc.
<br />1996 Don Lee Place Ste. C
<br />Escondido, CA 92029
<br />Transporter 1 Acknowledgement of Recei t atei
<br />Signature
<br />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 />Waste Management
<br />1390 E Commercial Row
<br />Reno, NV 89512
<br />Phone(775)326-2409
<br />Permit #: MSWL-003
<br />1 TOTALS 10==> I'/;&14 I ❑ 7E, Transfer Facility:
<br />Applicable permit numbers: Escondido- 5688 — MW -172 28 Healthcare Solutions, Inc.
<br />PP pe 428D Bandni Blvd.
<br />Print /Typed Name 1q14,
<br />1'1
<br />5. I Transporter 2 AddressAmlgh Systems Transportation Phone #: (800) 897-5571
<br />J (,4*1f 9M Ave, Scottsbluff, 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 />0 TO terminated New TO #
<br />Permit number:
<br />Date
<br />Phone #: (760) 489-5009 Vernon, CA 90058
<br />Vernon- 5688 — W-157 Phone (323) 307-0514,
<br />Phone (323) 307-05 Permit #:TS/OST 81
<br />Signature
<br />�Date / / 1? Date
<br />7. Treatment Facility Printed Certification of Receipt and Treatment
<br />1 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 />L7A. Transfer Facility:
<br />E
<br />WM Heallncare Solutions, Inc.
<br />3570 Enterprise Ave.
<br />CL
<br />Hayward, CA 9,1545
<br />y
<br />Phone (512),^56-890,
<br />t
<br />Permit a: TS -96
<br />Signature
<br />n
<br />Q m E
<br />2a. Description of Waste 2b. Container Type 12c. No r..,�►.tof
<br />�,a.a I za. Ib. or L
<br />Volume
<br />Regulated Med+caiWa5te,N.U.S., 6.2 31 GALLON (Regulated Medical Waste (Bic)) 31 gal
<br />O UN 3291, PGII
<br />RegulatedMedicalWast,:N.O.S, 6.2 O gulated MedicalWaste (Sio)) 43 gal
<br />UN 3291, PGIi
<br />OQ
<br />W
<br />t9
<br />J Transporter 1 is to check box if this is a through shipment
<br />c�
<br />E
<br />c8
<br />Transporter 1 Address: WM Healthcare Solutions, Inc.
<br />1996 Don Lee Place Ste. C
<br />Escondido, CA 92029
<br />Transporter 1 Acknowledgement of Recei t atei
<br />Signature
<br />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 />Waste Management
<br />1390 E Commercial Row
<br />Reno, NV 89512
<br />Phone(775)326-2409
<br />Permit #: MSWL-003
<br />1 TOTALS 10==> I'/;&14 I ❑ 7E, Transfer Facility:
<br />Applicable permit numbers: Escondido- 5688 — MW -172 28 Healthcare Solutions, Inc.
<br />PP pe 428D Bandni Blvd.
<br />Print /Typed Name 1q14,
<br />1'1
<br />5. I Transporter 2 AddressAmlgh Systems Transportation Phone #: (800) 897-5571
<br />J (,4*1f 9M Ave, Scottsbluff, 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 />0 TO terminated New TO #
<br />Permit number:
<br />Date
<br />Phone #: (760) 489-5009 Vernon, CA 90058
<br />Vernon- 5688 — W-157 Phone (323) 307-0514,
<br />Phone (323) 307-05 Permit #:TS/OST 81
<br />Signature
<br />�Date / / 1? Date
<br />7. Treatment Facility Printed Certification of Receipt and Treatment
<br />1 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 />
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