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WASTE INVIANASIEMENT <br />wwuze <br />MEDICAL WASTE:TRAP?J1:3 R, �UMENT: <br />SERVICE DATE: 11111111 loll 111111111-111 <br />ROUTE No. - SA204 TRUCK NUMBER DocuMENT <br />Seq. <br />Generator No. <br />2A• -Hour Emergency Response <br />:?,A.,Trattsfer Facitiiiy: <br />49 Tt�Aqy IVPa IN <br />(800) 424=9300`��� <br />04$-680002<;Ai.P,. <br />1530 Bessie As@ #108 <br />State Generator's ID No. <br />Tracy, CA 95376-3080;,. <br />} <br />Generator's US EPA ID No. <br />....... ........ - <br />�.. ,. <br />Debbie i3ettion <br />M�a <br />2a. Description of Waste <br />2b. Container Type 2c No of <br />lb. or <br />2d' Voume'733i.Ttansfer�Eac <br />. •. <br />UN 3291, PGll11 <br />ego Medical a o gal: <br />; • �w � . m,� . .i , <br />� <br />bne <br />U=PGii <br />Wa <br />)A <br />diGalwaskhmo•11LrMPS <br />UN 3291, PGIi <br />,.. <br />Signature <br />a fit+ <br />4 s p$�e `� <m <br />u <br />mated MedicaWa N,O.S. 6.2 <br />CInci ! <br />� �M��• �} �. , r. , �i <br />50SSiaie;ry65 <br />Pl <br />u <br />i Regulated Medical Waste, N.O.S., 6.2 <br />SHARPS PharmaceuIlC I.. � <br />Regulated Medical Waft N.O.S., 6.2 <br />SHARPS,(Regulated Medical Waste B 0 al <br />Regulated MedlealWaft RO.S.,.6.2 <br />SHARPS (Regulated Medlcal Waste (lo)) 0 gal .,. <br />! , .�, � �rFaci 1tv <br />q <br />Re uiatedMedicalWasKN.O.S.,6.2 <br />... . SHARPS PhaitllaCellbCai.Wa 40 8! <br />3 at\{s ,.•li <br />r 7E� Hellon Facil <br />4. <br />If Is <br />TOTALS ��,% <br />Trans orter 1 is to check box this a through shipmentEl <br />*' Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit numbers: Escondido- 5688 — MW -172 `1).` `Eq t <br />1996 Don Lee Place Ste. C Phone #: (760) 489-5009 1.F Y Y` ` ` ' k• <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of Receipt of Materials Vernon -5680— — W-187 ?�(��u; � >.•••••• <br />°" P 9 P hone : (323) 307-0,04 � t . . % <br />c <br />E /?�kSI Hato �'� <br />Signature Print /Typed Name I � Y! Date <br />5. Transporter 2 Address: Phone #: () 7. Treatment Facility Printed Certification of Receipt and Treatment <br />N "I certify that the contents of the listed containers have been received, treated <br />a ® and disposed of in accordance with all local, state, and federal regulations." <br />CL c Print Name <br />a <br />Signature Permit number. <br />Print / Tvved Name Date <br />eC <br />�o <br />_..,i Discrepancy <br />Comments <br />OTO terminated New TD # <br />Signature <br />[ <br />