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Q: <br />x <br />n <br />VWUYO MEDICAL WASTE TRACKING DOCUMENT <br />SERVICE DATE: 12/06/2011 <br />WANT■ F*IU%N^anmm 11T ROUTE NO. — SA204 TRUCK NUMBER <br />medwastemm.com <br />Seq Generator No. 1 949-6$0001 24 -Hour Emergency Response <br />0 1. SUTTER TRACY CONWNITY (800) 424-9300 <br />HOSPrrA State Generator's ID No. <br />949-680001 <br />1420 N Tracy Blvd <br />Tracy, CA 95376-3451 Generator's US EPA ID No. <br />2a. Description of Waste <br />Regulated Medical Waste, N.O.S., 6 <br />UN 3291, PGII <br />Regulated Medical Wask% N.O.S., 6. <br />UN 3781, PGI1 <br />Pharmaceutical Waste, <br />Pharmaceutical Waste <br />PGII <br />�ZCE <br />Pharmaceutical Wasle <br />2b. Container Type 2c. No of <br />Contalnei <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 />C] 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 of Receipt of Matet <br />Signature <br />JQ11111 111111111111II <br />DOCUMEN 0000442957 <br />Lj 7A: Transfer Facility: <br />WM Healvicare Solutions, Inc. <br />3670 Enterprise Ave. <br />f fayvaa,d, CA 04545 <br />Phone, (512) 355 8501 <br />Pemtit#: TS -96 <br />Signature <br />Ib. or B. Transfer Facility: <br />Volume WM Healthcare Solutions, Inc. <br />5337 Luce Avenue, BLDG 243E <br />McClellan, CA 95652 <br />Phone (512) 356-8907 <br />Permit #: TS -98 <br />Signature <br />Date <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 />TOTALS ��� E1 7E. Transfer Facility: <br />vvm Healthcare Solutions, Inc. <br />Applicable permit numbers: Escondido- 5688 – MW -172 4280 Bandini <br />Blvd. <br />Print / Typed Name ) [%'b <br />5. J Transporter 2 Address: gmlth-*sterns Transportation Phone #: (800) 897-5571 <br />417 9`h 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 />J Discrepancy <br />—� Comments <br />F] TD terminated New TD # <br />Permit number: <br />Date <br />Phone #: (760) 489-5009 Vemon, CA 90058 <br />Vernon- 5688 – -157 Phone (323) 307-0514 <br />hone #-/323) 307-051 / SgnPermit #;TSIOST Si <br />ct Date CD i� Signature <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 />19 <br />O <br />