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Lplu�ze <br />WASTE MANAOEME111T <br />Seq I Generator No. <br />MEDICAL WASTE TRACKING DOCUMENT <br />SERVICE DATE: 12/06/2011 <br />ROUTE NO. — cA111A TRUCK NUMBER <br />0 1' SUTTER TRACY COWNIUNITY <br />HOSPITA <br />949-680001 <br />1420 N Tracy Blvd <br />Tracy, CA 96376-3461 <br />2a. Description of <br />Medical Waste, N.O.S., 6. <br />2b. Container Type <br />24 -Hour Emergency Response <br />(800) 424-9300 <br />State Generator's ID No. <br />Generator's US EPA ID No. <br />31 GALLON (Regulated Medical Wa004031 gal-,, <br />Medical Waste, N.O.S., 6.21 43 GALLON <br />JTransporter 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 Receipt of Materials <br />Signature <br />Waste (Bio)) 43 gal <br />11 <br />TOTALS MC* <br />2c. No of <br />Applicable permit number/s: Escondido- 5688- MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 5688 - MW -157 <br />Print/ Typed Name <br />5. Transporter 2 Address: Skin -SyAtems Transportation Phone #: (800) 897-5571 <br />a 417 9'h Ave, Scottsbluff, NE 69361 <br />e� d P.O. Box 2455, Scottsbluff, NE 69363 <br />CLE C Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />W = Signature Permit number: <br />~ Print/ Typed Name Date <br />7A. Transfer Facility: <br />CD <br />CD <br />Discrepancy <br />AIM, Healthcare Solu:laaAs, inc. <br />c <br />� <br />` ii <br />3679 EnIcnprl5e Ave. <br />c <br />Comments <br />G <br />Hayward, CA 9•$548 <br />a <br />P?'nnr 512? 356-8901 <br />c g <br />a <br />Perri t � f5 or, <br />w id <br />g. <br />Signature-__ _ <br />� N <br />Z <br />Date <br />d .2 <br />WMRRRC <br />o <br />Ib. or <br />Volume <br />B, Transfer Facility: <br />12Q <br />> § <br />Applicable permit number/s: Escondido- 5688- MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 5688 - MW -157 <br />Print/ Typed Name <br />5. Transporter 2 Address: Skin -SyAtems Transportation Phone #: (800) 897-5571 <br />a 417 9'h Ave, Scottsbluff, NE 69361 <br />e� d P.O. Box 2455, Scottsbluff, NE 69363 <br />CLE C Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />W = Signature Permit number: <br />~ Print/ Typed Name Date <br />Date ✓12, <br />6' <br />u « <br />Discrepancy <br />iVICG s +an, CA 95652 <br />nE <br />` ii <br />o <br />�0 <br />Comments <br />G <br />TD terminated New TD # <br />Date ✓12, <br />Treatment Facility Printed Certification of Receipt and Treatment <br />7.J`I certify that the contents of the listed container/s have been received, treated c ig <br />and disposed of in accordance with all local, state, and federal regulations." E <br />Print Name v c li <br />Signature <br />V oc a� $ <br />m m c •- v <br />_O CL <br />O C L O 0) <br />N <br />Eli <br />( <br />C7�c <br />ElDate <br />=gifts iie:Ittxca, bel €iasis, Inc. <br />X337 ce Avenue, BLDG 243G <br />m <br />iVICG s +an, CA 95652 <br />3 <br />` ii <br />�Phana 7512)356-8907 <br />o rn <br />G <br />Permit #: TS -98 <br />a <br />Qate . <br />g. <br />� N <br />Z <br />7C: Incineration Facility: <br />o <br />WMRRRC <br />o <br />7505 State Hwy 65 <br />Anahuac, TX 77514 <br />Z! o <br />Phone (409) 267-3913 <br />m <br />Permit #: MSW 2239•A <br />Iii <br />$ <br />_ <br />c of <br />L S' 6. Autoclave Facility: <br />- N <br />o <br />d g <br />E <br />Waste Management <br />N � <br />!° <br />z o <br />1390 E Commercial Row <br />Reno, NV 89512 <br />v, m 2 <br />d <br />p <br />Phone(775)326-2409 <br />5 <br />5, & <br />l'- t <br />Permit#: MSWL-003 <br />0 <br />IWH-004 <br />r •9 m <br />c T n <br />« a <br />S <br />E] 7E. Transfer Facility: ` <br />n <br />I <br />WM Healthcare Solutions, Ina. <br />aca <br />d `° oe <br />is <br />>n <br />4280 i3andini 1310. <br />w a c <br />~ <br />Vemon, CA 90058 <br />79 v <br />a <br />Phone (323) 307-0514 <br />2 a 2 <br />Permit #:TS/OST 81 <br />m a <br />o <br />Signature <br />� <br />a o <br />'s / <br />Date <br />d a 0)c <br />L ql <br />. <br />Treatment Facility Printed Certification of Receipt and Treatment <br />7.J`I certify that the contents of the listed container/s have been received, treated c ig <br />and disposed of in accordance with all local, state, and federal regulations." E <br />Print Name v c li <br />Signature <br />V oc a� $ <br />m m c •- v <br />_O CL <br />O C L O 0) <br />N <br />Eli <br />( <br />C7�c <br />ElDate <br />