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MEDICAL WASTE TRACKING DOCUMENT <br />wwrne SERVICE <br />D <br />11111 <br />0-1/10/2012 <br />WASTE MANAGEMENT <br />a <br />medwaste.wm.com ROUTE No. W <br />TRUCK NUMBER <br />!11�_J _ <br />1 <br />Seo I Generator No. <br />0 1' ' S R TRACY CONMJNrry..: <br />HOSPITA <br />949.680001 <br />..1420 N Tracy Slid <br />Tracy, CA 95376.3451 <br />2e. Description of <br />Medical Wasp, N.O.S., <br />Mt N.O.S., <br />Pharmaceutical Waste, Pttarrnea <br />Wast, <br />Regulated Medical Waste, N.O.S., <br />LIN 3191, PGII <br />Regulated Medical Waw, N.O.S., <br />LIN 3291, PGIt <br />2b. Container Type <br />24-Hour Emergency Response <br />(800) 424-9300 <br />State Generator's ID No. <br />Generator's. US EPA ID No. <br />31 GALLON (Regulated. Medical Chemotherapy Waste) 31 gal <br />31 GALLON (Regulated Medical Pathological Waste) 31,gal.., <br />31 GALLON (Pharmaceutical Waste) 31 gal <br />43 GALLON (Regulated Medical Chemotherapy Waste) 43 gal: <br />Medical Pathological Waste) 43 gal <br />JTransporter 1 Is to check box if this is a through shipment El <br />Transporter 1 Address: WM Healthcare Solutions, Inc. <br />d 1996 Don Lee Place Ste. C <br />Escondido, CA 92029 <br />Transporter 1 Acknowledgement of Receipt o Udate <br />~ Signature--- <br />2c. No of <br />C C <br />TOTALS E=>ransfer Facility: ( _ •Q a` <br />Applicable permit number/s: <br />Print/Typed Name �� <br />5, Transporter 2 Address: Smit Systems ransportatlon Phone #: (800) 897-5571 <br />of 417 9 sbluff, NE 69361 <br />9 P.O. Box 2455, Scottsbluff, NE 69363 <br />C Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />c= Signature Permit number: <br />F- Print /Typed Name Date <br />6. Discrepancy <br />1 Comments <br />G� <br />TD terminated New TD # <br />❑ 7A. Transfer Facility: <br />Healthcare Environmental Service, <br />Escondido- 5688 — MW -172 <br />WM Healthcare Solutions, Inc. <br />�a�i <br />�, r <br />Phone #: (760) 489-5009 <br />3670 Enterprise Ave. <br />Hayward, CA 84545 <br />,q <br />g m <br />Vernon- 5688 — MINA 57 <br />j Phone (323) 307.0514 <br />Phone (512) 356-8801 <br />Phone #• (323) 307-0514 <br />i Permit #;T$/OST 81 <br />I Signature I' <br />Permit #: TS -96 <br />Signature <br />- Date <br />Date I <br />a o <br />Date <br />95 <br />S. Transfer Facility: <br />2d. Ib. or <br />.o 1 <br />Volume <br />WM Healthcare Solutions, Inc. <br />m <br />� � <br />5337 Luce Avenue, B G 243G <br />ro <br />McClellan, CA 56 <br />Phone (512) 6 8 <br />Permit #: TS• <br />Signat 6 <br />Date <br />0 ( a <br />r <br />120 <br />7C. Incineration Facility: <br />cc o LL <br />FRRC <br />c <br />State Hwy 85 <br />Anahuac, TX 77514 <br />, <br />I 12 Ilkf° <br />Ll �% <br />Phone (409) 267-3913 <br />Permit #: MSW 2239-A <br />( 10 8 <br />o <br />® Q=. 3 <br />E c ui <br />7D. Aut lave Facility: <br />.� o <br />Waste Management <br />a <br />1390 E Commercial Row <br />Reno, NV 89512 -• <br />Phone (775) 26-240 <br />' <br />I $ <br />`5. <br />Permit #: - <br />Q4 <br />o c y g <br />C C <br />TOTALS E=>ransfer Facility: ( _ •Q a` <br />Applicable permit number/s: <br />Print/Typed Name �� <br />5, Transporter 2 Address: Smit Systems ransportatlon Phone #: (800) 897-5571 <br />of 417 9 sbluff, NE 69361 <br />9 P.O. Box 2455, Scottsbluff, NE 69363 <br />C Intermediate Handler 2 / Acknowledgement of Receipt of Materials <br />c= Signature Permit number: <br />F- Print /Typed Name Date <br />6. Discrepancy <br />1 Comments <br />G� <br />TD terminated New TD # <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I certify that the contents of the listed container/s have been received, treatedco Z <br />and dispo f I ord nce 't ail e, nd derai regulations." 0 <br />Print Name tt$ <br />Signatu <br />Alternate Facility used for Incineration: <br />Heakhcare Solutions, Inc. <br />Healthcare Environmental Service, <br />Escondido- 5688 — MW -172 <br />42BO Bandinl Blvd. <br />�a�i <br />�, r <br />Phone #: (760) 489-5009 <br />Vernon, CA 90058 <br />a " <br />Vernon- 5688 — MINA 57 <br />j Phone (323) 307.0514 <br />701-28Z-7374 <br />Phone #• (323) 307-0514 <br />i Permit #;T$/OST 81 <br />I Signature I' <br />o <br />- Date <br />Date I <br />a o <br />m s' <br />7. Treatment Facility Printed Certification of Receipt and Treatment <br />"I certify that the contents of the listed container/s have been received, treatedco Z <br />and dispo f I ord nce 't ail e, nd derai regulations." 0 <br />Print Name tt$ <br />Signatu <br />Alternate Facility used for Incineration: <br />L U — <br />a <br />Healthcare Environmental Service, <br />IJ <br />Inc <br />1420 40th St North <br />y6 <br />`q <br />Fargo, ND 58102 <br />o <br />701-28Z-7374 <br />Incinerated on: Feb 13, 2012 <br />(}mac <br />Date <br />