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MEDICAL WASTE TRACKING DOCUMENT <br /> WVRZ. SERVICE DATE: 01/14/2014 i f <br /> WASTE MANAGEMENT <br /> medwaste.wm.com ROUTE NO.— SA203 TRUCK NUMBER DOCUMENT M 0001224673 <br /> Seq Generator No. 94$-580024 24-Hour Emergency Response ❑7A.Transfer Facility: m <br /> ,. 800 424-9300 Chemtrec# E <br /> STOCKTON SURGERY CENTER CCN24117 WM Healthcare Solutions,Inc. o, <br /> 8011 Don AVe3670 Enterprise Ave. <br /> Stockton GA 95209 28L1 State Generator's ID No. Hayward,CA 94545 r <br /> Phone(512)356-8901 0 <br /> (sea) 855,3001 Permit#:TS-96 8- <br /> 0.n E <br /> Katrina Holmes Generator's US EPA ID No. Signature 2 c d <br /> Date <br /> 2a.Description of Waste 2b.Container Type 2c. No of 2d. ib.or 7B,Transfer Facility: a o <br /> Containers volume i <br /> UN3291,Regulated MedleaiWaete, 31 GALLON(Regulated Medical Waste(81o)) gat al WM Healthcare Solutions,Inc. <br /> ® N.O.S.,6.2 PGii <br /> 5337 Luce Avenue,BLDG 243G a 3 <br /> �,. Ufam,Regulated Medical Waste, 43 GALLON(Regulated Medical Waste(B1oy) 3 McClellan,CA 95652 �LM g <br /> N.O.S.,8.2,PGII Phone(916)830-0533 H a c <br /> Permit#:TS-98 a <br /> W Signaturey CL <br /> .L <br /> Dale__%_ <br /> W ❑7C.incineration Facility: m a B <br /> v Curtis eaj m g m <br /> 3200 Hav � —''v <br /> Baltimore <br /> Phone(4' w " Q.r <br /> Permit o °u <br /> l a v m w <br /> ❑7D.G J rnc0 E E <br /> ❑Tr N •y N to <br /> Daniels! w m C v <br /> 4144EI i' ¢ 'n fwd d <br /> Fresno, <br /> I <br /> to c 'o <br /> Phone <br /> Permit# 3 v H c m LL <br /> 4. ;77E9." <br /> turi oW o m m <br /> Transporter 1 is to check box if this is a through shipment O TOTALS ��� o o+ c--q <br /> a W <br /> P 4 d <br /> Transporter 1 Address: WM Healthcare Solutions,Inc. Applicable permit number/s: Escondido-5688—MW-172 _ ° ~ v rn <br /> 1996 Don Lee Place Ste.C Phone#:(760)489-5009 <br /> o Escondido,CA 92029 Spoke LL to o; <br /> Q. Vernon-5688—MW-157 2900 <br /> U) Transport r Acknowledgement of Receipt of Materials Phone# 323 07-0514 s k< a` a <br /> ( ) Phos, o f <br /> F Perini a Z r °' a <br /> Signature Print lTyped Name Date SHRD'b`WZP0al2swuraw, d <br /> 5. Transporter 2 Address: Phone M ( ) 7. Treatment Facility Printed Certification of Receipt and Treatment t " <br /> "I certify that the gontents of the listed containers have been received, e� E o <br /> C•c`? treated and disposed of at one'or mor6 of the facilities indicated below in o E E r <br /> Ntv <br /> E accordance with all local,state,and federal'regulatiorts" <br /> = Signature Permit number. �' c <br /> i Print/Typed Name Date 7C ❑ ) n n <br /> 6. JAN 16 2014 N y <br /> � _ <br /> Discrepancy 7D ❑ $ @ c <br /> C <br /> M E 7E ❑ Derek Rumsey CFO <br /> y Comments <br /> ® 7vG�Mti <br /> vi TD terminated New TD 9 � ❑ <br />