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MEDICAL WASTE TRACKING DOCUMENT wwuza SERVICE DATE: 12/13/2011 W"TE MA111"EMEIYT ROUTE NO. — SA204 TRUCK NUMBER DOCUMENT #: 0000442958 m&dwagte_wm.com _ _- Transporter 1 Address: WM Healthcare Solutions, Inc. 1996 Don Lee Place Ste. C Escondido, CA 92029 Transporter 1 Acknowledgement of Receipt of Materials ~ Signature E o8 Applicable permit number/s Print / Typed Name 5. I Transporter 2 Address: Zffiltti Systems Transportation Phone #: (800) 897-5571 J Ave, Scottsbluff, NE 69361 P.O. Box 2455, Scottsbluff, NE 69363 Intermediate Handler 2 / Acknowledgement of Receipt of Materials Signature Print / Typed Name _ 6. Discrepancy Comments aTD terminated New TD # Permit number Date Escondido- 5688 — MW -172 Phone #:(760)489-5009 Vernon- 5688 MW -157 Phon #: (323) 307-051X Date vvM neauncare solutions, Inc. 4280 Bandini Blvd. Vernon, CA 90058 Phone (323) 307-0514 Permit #:TS/OST 81 Signature Date 7. Treatment Facility Printed Certification of Receipt and Treatment "I certify that the contents of the listed container/s have been received, treated and disposed of in accordance with all local, state, and federal regulations." Print Name Signature Date e SeqGenerator No. 24 -Hour Emergency Response 117A. Transfer Facility: (800) 424-9300 WM Healthcare Solusions, inc. ,C59 545 Haywad.A Phone (512);356;5901 U SUTTER TRACY COMMNITY HOSPITA 949-680001 State Generator's ID No. 1420 N Tracy Blvd Tracy, CA 95376-3451 Permit*18.136 Signature - Generator's US ERA ID No, (209) 832-6012-- O 7B. Transfer Facility: WM Healthcare Solution Inc. Luce Ave 243G McClellan; C Phone (5t2), 7 Permit #: T Signature 2a. Description of Waste 2b. Container Type 2c. No of Containers 2d. ib. or Volume UN 3291, PGII (RegulatedMedical Chemotherapy 8 gal5337 UN 3241, PGII W PharmaceuticalWasle e Incineration Facility, WMRRRC 505 State Hwy 65 W Reaulated Medical Wasle NOS. 6 2 UN 3291, PGII Re mated Medical Wash N.O.S. 6.2 43 GAI I ONI (R*91 llzUri Medical Chemotherapy WaSU) 43 gal / Anahuac, TX 77514 Pharmaceutical Waste, 43 GALLON Pharmaceubcal Waste 43 gal Phone (409) 267-3913 Permit #: MSW 2239-A 7D. Autoclave Facility: Waste Management 1390 E Commercial Row Reno, NV 89512 Phone (775) 326-2409 Permit M MSWL-003 IWH-004' 4. Transporter 1 is to check box if this is a through shipment El TOTALS �� t— 7E. Transfer Facility: Transporter 1 Address: WM Healthcare Solutions, Inc. 1996 Don Lee Place Ste. C Escondido, CA 92029 Transporter 1 Acknowledgement of Receipt of Materials ~ Signature E o8 Applicable permit number/s Print / Typed Name 5. I Transporter 2 Address: Zffiltti Systems Transportation Phone #: (800) 897-5571 J Ave, Scottsbluff, NE 69361 P.O. Box 2455, Scottsbluff, NE 69363 Intermediate Handler 2 / Acknowledgement of Receipt of Materials Signature Print / Typed Name _ 6. Discrepancy Comments aTD terminated New TD # Permit number Date Escondido- 5688 — MW -172 Phone #:(760)489-5009 Vernon- 5688 MW -157 Phon #: (323) 307-051X Date vvM neauncare solutions, Inc. 4280 Bandini Blvd. Vernon, CA 90058 Phone (323) 307-0514 Permit #:TS/OST 81 Signature Date 7. Treatment Facility Printed Certification of Receipt and Treatment "I certify that the contents of the listed container/s have been received, treated and disposed of in accordance with all local, state, and federal regulations." Print Name Signature Date e