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MEDICAL WASTE TRACKING DOCUMENT <br />WWRze SERVICE DATE: 11/2W011 <br />WAS" MAIVAsa EMErAs ROUTE NO. _ SA204 TRUCK NUMBER <br />W stem tt-Com <br />Sep Generator No. 4-08000 24 -Hour Emergency Response <br />0 SUTTER IVIG CTR (800) 424-9300 <br />M-680002 State Generator's ID No. <br />1530 Bessie Ave 0100 <br />Tracy, CA 85338-3080 Generator's US EPA ID No. <br />2a. Description of Waste <br />Regulated MedlcafflaM N.0.9-, <br />UN 3291. PGi1 <br />Regulated NedkalWaste, NO.S., <br />UN 3231, PGII <br />2b. Container Type <br />• : r r - r : ,� a =. <br />Medical Waste (Blo)) 43 gal <br />I " i Transporter 1 is to check box if this Is a through shipment El <br />L Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of Receipt of M 'ais <br />E <br />Signature Cr1 <br />E <br />G� <br />Applicable permit numbeds: <br />Print/ Typed Name <br />5. Transporter 2 Address: SmitA Systefns Transportation Phone #: (800) 897-5571 <br />— 417 9ei Ave, Scottsbluff, NE 69361 <br />P.Q. Box 2455, Scottsbluff, NE 69363 <br />Intermediate Handler 21 Acknowledgement of Receipt of Materials <br />Signature <br />Print/ Typed Nares _ <br />=i Discrepancy <br />QTD terminated New TD # <br />Permit number. <br />Date <br />e e 1 i k fit 11,r . • <br />No of I ao. m. or <br />Escondido- 5688 — MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 6688 — MW -157 <br />Phone #: (323) 307-0514 <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I certify that the contents of the listed containeds have been received, treated <br />and lisp anc a with alpiosa4 te, an federal regulations." <br />Print Name (je <br />Data 1J.-Ij ( . <br />