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F-77 <br />MEDICAL WASTE TRI'-K!�G-POCUMENT <br />SERVICF- DATE: <br />ROUTE No. - TRUCK NUMBER <br />4 <br />UOICUMENTIF: <br />V- Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit numbeds: Escondido- 5688—MW-172 4144 E Therese Ave. <br />Seq <br />Generator No. I <br />24 -Hour Emergency Response <br />07A. Transfer Facility: <br />Signature —Print /Typed Name Date Date <br />777777, T. <br />424-9300 <br />WM Healthcare Solutions. Inc. <br />-�]"[ certify that the contents of the listed containeds have been received, treated <br />21. <br />(800) <br />3670 Enterprise Ave. <br />ro 0 <br />Print Name <br />Haywatd, CA 124645 <br />Signature Permit number: <br />State Generator's ID No. <br />Phone (512) 356 <br />Print/ Typed Name Date <br />Permit #: TS -96 <br />6' <br />Signature <br />Generator's US EPA ID No. <br />Date - <br />0 7B, Transfer Facility: <br />E <br />E <br />0 <br />Comments <br />2a. Description <br />of Waste <br />2b. Container Type <br />2c. No of <br />2d. lb. or <br />F]TD terminated New TO # <br />Signature Date <br />Containers <br />Volume <br />WM Healthcare Sotutions, Inc. <br />77! 7 7 1! !M 771-- <br />5337 Luce Avenue, BLDG 2430 <br />McClellan, CA 95652 <br />Phone (612) 356-8907 <br />q� <br />Permit #: TS -98 <br />Signature— <br />U <br />Date — <br />7C. incineration Facility: <br />t❑ <br />Af <br />14 <br />WMRRRC <br />7505 State Hwy 65 <br />Anahuac,TX 77514 <br />i iVJ;� ):41'- i�i 01 <br />Phone (409) 267-3913 <br />Permit- MSW 2239-A <br />--E] <br />7D. Alternate Facility: <br />0 <br />Transporter I Is to check box It this Is a through shipment F-1 I <br />TOTALS EOL-� <br />� / <br />I <br />Lj 7E. Destination Facility: <br />V- Transporter 1 Address: WM Healthcare Solutions, Inc. Applicable permit numbeds: Escondido- 5688—MW-172 4144 E Therese Ave. <br />1996 Don Lee Place Ste. C Phone #: (760) 489-5009 Fresno, CA 93725 <br />0-0 <br />Escondido, CA 92029 Vernon- 5688 — MW -157 Permit hone (559) 834-6252 <br />P #: TSIST 55 <br />O <br />Transporter 1 Acknowledgement of Receipt of Materials Phone 11: (323) 307-0514 <br />Signature_ <br />Signature —Print /Typed Name Date Date <br />5. Transporter 2 Address: Phone #:( <br />7• Treatment Facility Printed Certification of Receipt and Treatment <br />-�]"[ 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 />ro 0 <br />Print Name <br />Signature Permit number: <br />Print/ Typed Name Date <br />6' <br />Discrepancy <br />E <br />E <br />0 <br />Comments <br />F]TD terminated New TO # <br />Signature Date <br />