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<br />MEDICAL WASTE TR. ING9ocuMENT
<br />SERVICE DATE'.
<br />�_R i
<br />ROUTE No. - - _0J TRUCK NUMBER
<br />'04 P t
<br />DocuMENT #:
<br />Transporter 1 Address: WM Healthcare Solutions, Inc.
<br />1996 Don Lee Place Ste. C
<br />Escondido, CA 92029
<br />0 Transporter 1 Acknowledgement of Receipt of Materials
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<br />12
<br />Signature
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<br />WM Healthcare Solutions, Inc,
<br />Applicable permit nurnbeds: Escondido- 5688 – MW -172 4280 Bandini Blvd.
<br />Phone 9: (760) 489-5009 Vernon, CA 90058
<br />Vernon- 5688 – MW -157 Phone (323) 307-0514
<br />Phone #: (323) 307-0514 Permit #:TS/OST 81
<br />Signature
<br />Print / Typed Name Date Date
<br />r I Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571
<br />417 9"' Ave, Scottsbluff, NE 69361
<br />P.O. Box 2455, Scottsbluff, NE 69363
<br />Intermediate Handier 2 / Acknowledgement of Receipt of Materials
<br />Signature
<br />Print/ Typed Name
<br />6.
<br />Discrepancy--,_
<br />Comments
<br />1-1 TD terminated Now To #
<br />Permit number:
<br />Date
<br />__.!Treatment Facility Printed Certification of Receipt and Treatment
<br />"I certify that the contents of the listed containeds have been received, treated
<br />and disposed of In accordance with all local, state, and federal regulations."
<br />Print Name
<br />Signature
<br />Date
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<br />Seq
<br />Generator No.
<br />" � 1 I' � ; �_- , "
<br />24 -Hour Emergency Response
<br />[:17A. Transfer Facility:
<br />(800) 424-9300
<br />WM Healthcare SolutionS, Inc.
<br />3670 Enterprise Ave.
<br />Hayward, CA 94545
<br />State Generator's ID No.
<br />Ph4ne(612)356-8901
<br />Permit #: TS -96
<br />;,p q;)ir
<br />Signature
<br />Generator's US EPA ID No.
<br />Date
<br />7BTransfer Facility:
<br />.
<br />2a. Description of Waste
<br />2b. Container Type
<br />2c. No of
<br />2d. lb. or
<br />Containers
<br />Volume
<br />WM Healthcare Solutions, Inc.
<br />717 M
<br />6337 Luce Avenue, BLDG 243G
<br />McClellan, CA 95652
<br />Phone 356-8907
<br />(512)
<br />Permit #: TS -98
<br />Signature
<br />Date
<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 />[:] 7D. Autoclave Facility:
<br />Waste Management
<br />1390 E Commercial Row
<br />Reno, NV 89512
<br />Phone (775) 326-2409
<br />Permit #-, MSWL-003
<br />IWH.004
<br />4.------
<br />Transporter I is to check box If this Is a through shipment El
<br />TOTALS 10 ------
<br />7E. Alternate Facility:
<br />Transporter 1 Address: WM Healthcare Solutions, Inc.
<br />1996 Don Lee Place Ste. C
<br />Escondido, CA 92029
<br />0 Transporter 1 Acknowledgement of Receipt of Materials
<br />r_
<br />12
<br />Signature
<br />E
<br />E
<br />0
<br />TO
<br />0
<br />WM Healthcare Solutions, Inc,
<br />Applicable permit nurnbeds: Escondido- 5688 – MW -172 4280 Bandini Blvd.
<br />Phone 9: (760) 489-5009 Vernon, CA 90058
<br />Vernon- 5688 – MW -157 Phone (323) 307-0514
<br />Phone #: (323) 307-0514 Permit #:TS/OST 81
<br />Signature
<br />Print / Typed Name Date Date
<br />r I Transporter 2 Address: Smith Systems Transportation Phone #: (800) 897-5571
<br />417 9"' Ave, Scottsbluff, NE 69361
<br />P.O. Box 2455, Scottsbluff, NE 69363
<br />Intermediate Handier 2 / Acknowledgement of Receipt of Materials
<br />Signature
<br />Print/ Typed Name
<br />6.
<br />Discrepancy--,_
<br />Comments
<br />1-1 TD terminated Now To #
<br />Permit number:
<br />Date
<br />__.!Treatment Facility Printed Certification of Receipt and Treatment
<br />"I certify that the contents of the listed containeds have been received, treated
<br />and disposed of In accordance with all local, state, and federal regulations."
<br />Print Name
<br />Signature
<br />Date
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