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MEDICAL WASTE TRACKING DOCUMENT <br />e SERVICE DATE: 04/10/2012 <br />WASTE MANAGNM®t11T <br />medaste.m.c®m ROUTE NO. — wicis TRUCK NUMBER <br />seq Generator No. 1 049-580024 . 24 -Hour Emergency Response <br />0 1 s-roCKTON SURGERY CENTER (800) 424-9300 <br />0.580024 State Generator's 10 No. <br />8011 Don Ave <br />Stockton, GA 95209-2841 <br />(208) 85543001 Generator's US EPA ID No. <br />2a. Description of Waste <br />Regulated Medical Wase, RCI.S•, 6. <br />LIN 3281, PGII <br />Regulated Medical Waste, N.O.S., 6. <br />LIN 3791, PGII <br />2b. Container Type <br />GALLON (Regulated Medical Waste (Blo)) 31 gal <br />(Regulated Medical Waste (Blo)) 43 gal <br />UTransporter 1 Is to check box if this Is a through shipment El <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 />..r II>l11� ►,�'1 <br />LJ 7A. Transfer Facility: <br />WM Healthcare Solutions, Inc. <br />3670 Enterprise Ave, <br />Hayward, CA 94545 <br />Phone(512)356.8901 <br />Permit M TS -98 <br />Signature <br />2c. No of 2d. lb. or ( Wig, Transfer Facility: <br />APR <br />Containers Volume <br />WM Healthcare Solutlons, Inc. <br />( <br />5337 Luce Avenue, BLDJ8 2430 <br />t <br />McClellan, C <br />7505 State Hwy 65 <br />Phone (6 12) 3y8 -y-, <br />Permit #: TS -1 <br />TOTALS E=> ( 1 <br />Applicable permit numbeds: Escondido- 5688 — MW -172 <br />Phone #: (760) 489-5009 <br />Vernon- 5688 — MW -157 <br />Phone #: (323) 307-0 14 <br />Print / Typed Name 6 YI., Date / C� <br />., 5, Transporter 2 Address: Smith Syst s nsportatlon Phone #: (800) 897.5571 <br />417 9a' Ave, cotta uff, NE 69361 <br />P.O. Box 245r, Seaftabluff, NE 69363 <br />Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />= Signature Permit number: <br />~ , Print /Typed Name Date <br />JDiscrepancy <br />Comments <br />7l TD terminated New TD # <br />— ---• - <br />Date i <br />c <br />d i <br />@ o <br />7C. Incineration Facility:: <br />WMRRRC <br />c <br />7505 State Hwy 65 <br />$' <br />Anahuac, TX 77514 <br />Phone <br />3 <br />(409) 267-3913 <br />Permit #: MSW 2239-A <br />d <br />B v <br />— a <br />7D. Autoclave Facility. <br />Waste Management <br />1390 E Commercial Row <br />Reno, NV 89512 <br />Phone (775) 326 <br />Permit #: MS 003 <br />�E• Transfer Facility: <br />WM Healthcare Solutions, Inc. <br />4280 Bandini Blvd, <br />Vernon, CA 90058 <br />Phone (323) 3070514 <br />Permit#:TS/0S781 <br />7• Treatment Facility Printed Certification of Receip 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 n n - <br />� w <br />t U U <br />APR 1 7 2012 <br />Signature Date <br />r <br />i <br />CL <br />v <br />E <br />C <br />H <br />X <br />LL <br />d <br />I - <br />