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Regulated Medical Waste <br /> PageRAcofING DOCUMENT s 7229731 <br /> CODE AREA <br /> yp(p y-{^ UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> SYSTEMS ; <br /> c� <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (209) 467-4661 <br /> ADDRESS <br /> p 7707 S. Austin Rd Stockton, CA 95215 <br /> F- <br /> I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br /> Lu <br /> packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br /> z <br /> LU U.S. Department of Transportation. <br /> Able G. /_jA/ 08-22-2024 1:47 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> Anthony Jenkins AJ 5039 <br /> COMPANY NAME TELEPHONE NUMBER <br /> w Med-Waste Systems, LLC (818) 998-5533 <br /> E— <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O <br /> a 4882 McGrath St Suite 320 Ventura, CA 93003 08-22-2024 1:47 PM <br /> /n <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> Q N cont. wC q q coot. wl, <br /> q q coot. wt.q g rant, w6 q 4 cont. wt. <br /> 13 51 19 209 <br /> > I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that <br /> cc <br /> falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> cc <br /> Anthony Jenkins 08-22-2024 1:47 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> ry NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> Anthony Jenkins AJ TS-167 <br /> tY COMPANY NAME TELEPHONE NUMBER <br /> O <br /> CL (Stockton) Mod-Waste Systems, LLC (818) 998-5533 <br /> Z a ADDRESS DATE MEDICAL WASTE COLLECTED <br /> F 4079 Cherokee Rd Stockton CA 95215 08-22-2024 3:21 PM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> O q Cont. wt.b q coot. vR.q p coot. wt,p p rant. wt.q p cant. wt.q <br /> t=- 13 51 19 209 <br /> H <br /> N I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load. I am aware that <br /> cc falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> LL <br /> w <br /> Anthony Jenkins 08-22-2024 3:21 PM <br /> cc <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> r— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> t< 4800 E Lincoln Ave Fowler CA 93625 <br /> Cr PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL' <br /> L- TSOST-89 08-29-2024 8:48 AM 260.00 <br /> to <br /> Z DISCREPANCY INDICATION SPACE <br /> Q <br /> H <br /> h <br /> z I certify that I have been authorized to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the <br /> w <br /> 2i requirements outlined in that authorization. <br /> I— <br /> w Jorge A 08-29 2024 8:48 AM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> In case of emergency, call ( 818 ) 998-5533 (24-hr company or other emergency response group telephone) <br /> Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations. <br />