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VWUYAO <br />WASTE MAIYAGEMENIT <br />medwaste.wm.com <br />MEDICAL WASTE TRACKING DOCUMENT <br />SERVICE DATE: 12/13/2011 <br />ROUTE NO. — S14204 TRUCK NUMBER <br />111111111 <br />oocuxemu:0000442933 <br />111111111111111 <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />o Escondido, CA 92029 <br />CL <br />Transporter 1 Acknowledgement of Receipt of Materials <br />~ Signature -7771 _--- <br />{ <br />vvM navjueons, mc. <br />Applicable permit numbers: Escondido- 5688 — MW -172 428) BandIni Blvd. <br />Phone #: (760) 489-5009 Vernon, CA 90058 <br />Vernon- 5688 W-157 Phone (323) 307-0514 <br />Phon #: W 3) 307-05 4 Permit #:TS/OST 81 <br />Signature <br />Print /Typed Name /7w b ! Date / DateIf <br />4-1 <br />5.� Transporter 2 Address: Sfilth Systems Transportation Phone #: (800) 897-5571 <br />4 ve, Scottsbluff, NE 69361 <br />P.O. Box 2455, Scottsbluff, NE 69363 <br />Intermediate Handier 2 / Acknowledgement of Receipt of Materials <br />Signature <br />Print / Typed Name _ <br />6. Discrepancy <br />—� comments _ <br />7 TD terminated New TD # <br />Permit number: <br />Date <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I 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 />I <br />Seq <br />Generator No. <br />24 -Hour Emergency Response <br />QTA, Trartaier Facility: <br />(800) 424-9300 <br />WM Healthcare SoIut4aha, Irc. <br />3670 Enterprise Ave. <br />Hayward, GA 94645 <br />Permit #., 356- 8901 <br />1. SUTTER TRACY COMMUNITY <br />HO SP ITA <br />$4$-860001 <br />State Generator's ID No. <br />1420 N Tracy Blvd <br />Signature <br />Tracy, CA 93376-3451 <br />Generator's US EPA ID No. <br />Date <br />209 832-6012 <br />Transfer Facility: <br />WM Hearihcare Soluti s, Inc. <br />5337 Luce Avenue G 243G <br />McClellan, C <br />Phone (512) 7 <br />Permit T <br />S'ignatu <br />2a. Description of Waste <br />2b. Container Type <br />2c. No of <br />Containers <br />2d. Ib. or <br />Volume <br />Regulated Medical Waste, N.O.S., 6.2 <br />UN 3291, PGII <br />RegtilatedliledfcalWa <br />UN 3291, PGII <br />31 GALLON (Regulated Medical Waste (Bio)) 31 gal <br />43 GALLON (Regulated ed Cal Waste (Blo)) 43 galC <br />j- <br />WE] <br />7C. Incineration Facility <br />Iw <br />V <br />WNIRPAC <br />7505 Siete Hwy 65 <br />AnahTX 77514 <br />Phon9) 267-3313 <br />.;MS4V 2 ; <br />70 <br />Wso ManagerC n! <br />1390 E t i)mrtaetdal Row <br />Reno, NV 89512 <br />Phone (775) 326-2409 <br />Permit #: MS) i -003 <br />4' <br />Transporter 1 is to check box if this is a through shipment ❑ <br />TOTALS �0� <br />�� 3 <br />E. Transfer Facility: <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />o Escondido, CA 92029 <br />CL <br />Transporter 1 Acknowledgement of Receipt of Materials <br />~ Signature -7771 _--- <br />{ <br />vvM navjueons, mc. <br />Applicable permit numbers: Escondido- 5688 — MW -172 428) BandIni Blvd. <br />Phone #: (760) 489-5009 Vernon, CA 90058 <br />Vernon- 5688 W-157 Phone (323) 307-0514 <br />Phon #: W 3) 307-05 4 Permit #:TS/OST 81 <br />Signature <br />Print /Typed Name /7w b ! Date / DateIf <br />4-1 <br />5.� Transporter 2 Address: Sfilth Systems Transportation Phone #: (800) 897-5571 <br />4 ve, Scottsbluff, NE 69361 <br />P.O. Box 2455, Scottsbluff, NE 69363 <br />Intermediate Handier 2 / Acknowledgement of Receipt of Materials <br />Signature <br />Print / Typed Name _ <br />6. Discrepancy <br />—� comments _ <br />7 TD terminated New TD # <br />Permit number: <br />Date <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I 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 />I <br />