Laserfiche WebLink
MEDICAL WASTE TRACKING DOCUMENT <br />vwns SERVICE DATE: 01/3112012 <br />WASTE MAMA®EMENT ROUTE N®. — TRUCK NUMBER <br />me ante. m.Com 5 204 <br />Seq Generator No. 24 -Hour Emergency Response <br />0 '' STOCKTON SURGERY CENTER (800) 424-9300 <br />949.580024 State Generator's ID No. <br />8011 DOR Ave <br />Stoddon, fid► 95209-2841 Generator's US EPA ID No. <br />(209) 955-3001 <br />2a. Description of Waste <br />Medical Wash, N.O.S., <br />medlcat Waste, N.D.S., <br />2b. Container Type <br />Medical Waste (Blo)) 31 gal <br />43 GALLON (Regulated Medical Waste (Blo)) 43 gal <br />L Transporter 1 is to check box if this Is a through shipment a <br />Transporter 1 Address: / WM Healthcare Solutions, Inc. <br />1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of Receipt of Materials <br />~ Signature <br />TOTALS 'IC=* <br />Applicable permit numberla: <br />Print/ Typed Name <br />5, 1 Transporter 2 Address: Sml Syste Transportation Phone #: (800) 897-5571 <br />N 41 417 " cottsbluff, NE 69361 <br />P.O. Box 2455, Scottsbluff, NE 69363 <br />Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />I = Signature Permit number: <br />}' <br />Print/ Typed Name Date <br />6._i Discrepancy <br />Comments <br />7 TD terminated New TD # <br />LJ7A. Transfer Facility: <br />YVM Healthcare Solutions, Inc. <br />3670 Enterprise Ave. <br />Hayward, CA 94545 <br />Phone (512) 356.8901 <br />Permit #: TS -96 <br />Signature <br />Date <br />2c. No of 2d. ib. or =13. Transfer Facility: <br />Containers Volume WIN Healthcare Solutions, to <br />5337 Luce Avenue,V72,G <br />McClellan,CA 95 Phone (512) 356 Permit #: TS -98 f . <br />Escondido- 5888 — MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 5888 — MW -157 <br />�Phone #: (323) 307.0514 <br />Date /A <br />/� i <br />® 7C. Incineration Facility: <br />WMRRRC <br />7505 State Hwy 65 <br />Anahuac, TX 77514 <br />Phone (409) 267-3913 <br />Permit #: MSW 2239-A <br />EJ 7. Autoclave Facility: <br />Waste Management <br />1390 E Commercial Row <br />Reno, NV 89512 <br />Phone (775) 326-2409 <br />Permit #: MSWL-003 <br />nater Facility: <br />WM Healthcare Solutions, Inc, <br />4280 Bandini Blvd. <br />Vernon, CA 90058 <br />Phone (323) 307-0514 <br />Permit #:TSICST 81 AS <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 />FEB 0 2 2012 <br />Signature Date <br />a� <br />y � <br />a� 'a <br />gC € <br />Q <br />m� <br />t � a <br />v � <br />✓D o a <br />u <br />m o` <br />c e <br />T A <br />� � U <br />E C <br />E a m <br />E <br />N a <br />c d ® T <br />G <br />I <br />,5 <br />ia. :5 <br />me <br />R o <br />a <br />0 <br />d— <br />s e o <br />R <br />G <br />C E <br />o2E <br />M <br />45 <br />0 -2 P; <br />pA <br />0 � roC � <br />woo w <br />e ' <br />� C � <br />C7wc <br />in <br />