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MEDICAL WASTE TRACKING DOCUMENT 11111111011111111 vwuze SERVICE DATE: 12/13/2011 WASTE MANAGEMENTROUTE NO. —W04 TRUCK NUMBER DOCUMENT #: 00004881, wrisad Wn1tte-W M. CiD111 L Transporter 1 Address: WM Healthcare Solutions, Inc. m 1996 Don Lee Place Ste. C o Escondido, CA 92029 CL Transporter 1 Acknowledgement of Receipt rials I— Signature v« 98 O Applicable permit number/s: Print / Typed Name 5. I Transporter 2 Address: Skbith Systems Transportation Phone #: (800) 897-5571 J 41 Ave, Scottsbluff, NE 69361 P.O. Box 2455, Scottsbluff, NE 69363 Intermediate Handier 2 / Acknowledgement of Receipt of Materials Signature Print / Typed Name _ 6. 1 Discrepancy Comments aTD terminated New TD # Permit number: Date Escondido- 5688 — MW -172 Phone #:(760)489-5009 Vernon -5688 MW -157 Phon;7#: (323) 307-05/4 vvm neatummia ouauuur14, ince. 4280 Sandinl Blvd. Vernon, CA 90058 Phone (323) 307-0514 Permit #-.TS/0ST 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 Seq Generator No. 24 -Hour Emergency Response 07A. Transfar F (800) 424-9300 3WM 670 Enterprise . 3&7th Enterprise Ave:`-- ,. SUTTER TRACY WMIGING CTR 949-580002 1530 Bessie Ave #109 Hayward, CA 94545 .- Phoria (512) 356-8901,, Permit #: TS -96 State Generator's ID No. Tracy. CA 95378-3080 Signature Generator's US EPA ID No. Date Debbie Denton O I Hea Transfer Facility: ,�,� tieaftiicare Solis, I c, 5337 Luce AvE 43G' McCle€uar<<, A 9 Phone {5 t2) 35 Permit #: TS Signature Date 2a. Description of Waste 2b. Container Type 2c. No of Containers 2d. m. or Volume Regulated Medical Waste, N.O.S., 6.2 UN 3291, PGIi egu a ca a . . , UN 3291, PGII 31 GALLON (Regulated Medical Waste (Blo)) 31 gal NRegUlated MedlEala 14) 43 gal(/ l 04kidl y W W,17G.Incini Iw v WMRRPC 7505 State Hwy 65 Anahuac, TX 77514 Phone (409) 267-3913 Permit #: MSW 2239-A ❑ 7D. Autoclave Facility: Waste Management 1390 E Commercial Raw Reno, NV W512 Phone (775) 326-2409 Permit#: MSWL-003 iSNH-004 4. Transporter 1 is to check box if this is a through shipment ❑ TOTALS ODE=:> Lt '3 7E. Transfer Facility L Transporter 1 Address: WM Healthcare Solutions, Inc. m 1996 Don Lee Place Ste. C o Escondido, CA 92029 CL Transporter 1 Acknowledgement of Receipt rials I— Signature v« 98 O Applicable permit number/s: Print / Typed Name 5. I Transporter 2 Address: Skbith Systems Transportation Phone #: (800) 897-5571 J 41 Ave, Scottsbluff, NE 69361 P.O. Box 2455, Scottsbluff, NE 69363 Intermediate Handier 2 / Acknowledgement of Receipt of Materials Signature Print / Typed Name _ 6. 1 Discrepancy Comments aTD terminated New TD # Permit number: Date Escondido- 5688 — MW -172 Phone #:(760)489-5009 Vernon -5688 MW -157 Phon;7#: (323) 307-05/4 vvm neatummia ouauuur14, ince. 4280 Sandinl Blvd. Vernon, CA 90058 Phone (323) 307-0514 Permit #-.TS/0ST 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