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MEDICAL WASTE TRACKING DOCUMENT <br />wwrae SERVICE DATE: 12/06/2011 <br />WASTE MAMAGEMEtNT ROUTE NO. — (14 TRUCK NUMBER <br />medWaStemm.C®m <br />S" Generator No. 1 949-680002 24 -Hour Emergency Response <br />0 1. SUTTER TRACY IVIAG ING CTR (800) 424-9300 <br />949-959902 State Generator's ID No. <br />1530 Bessie Ave #109 <br />Tracy, CA 99379.3080 Generator's US EPA ID No. <br />• rrrr.-• <br />2a. Description of Waste 2b. Container Type 2c. No of 2d. lb. or <br />Containers Volume <br />4 Regulated MEedlcal Waste, N.O.S., 6.2 SHARPS (Regulated Medical Waste (Blo)) 0 gat <br />UN 3291 PGII <br />Regulated Mtedical Wasle� N.O.S., 6.2 SHARPS (Pharmaceutical Waste) 0 gal <br />UN 3291, 13811 <br />w <br />Regulated kledlcalWa*N.O.S., 6.2 SHARPS (Regulated Medical Waste (Slo)) 0 gal <br />UN 3291, PGII <br />w Regulated Miedlcal Wast KO.S., 6.2 SHARPS (Pharmaceutical Waste) 0 gal <br />UN 3291, PGII <br />u a a ca a ., armaceutical Waste) 0 ge <br />UN 3291, PGiiz x , " I I—Ali <br />UN 3291, PGII <br />UNM, PGII <br />pmd.#�..j U. :K <br />uN m. PGII <br />C <br />�E <br />D <br />_! Transporter 1 is to check box If this Is a through shipment a <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 />5. 1 Transporter 2 <br />TOTALS �0� <br />Applicable permit number/s: Escondido- 5688 — MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 5688 — MW -1 57 <br />(323) 307-0514 <br />Print / Typed Name lykL I IDate KUate'® <br />Phone#: (} 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 disposed of in accordance with all local, state, and federal regulations." <br />Print Name <br />Signature Permit number:— <br />Print/ <br />umber:Print/ Typed Name Date <br />J Discrepancy <br />Comments <br />RTD terminated New TO # <br />Signature <br />