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Regulated Medical Waste <br /> PagffRA(D NG DOCUMENT# 7258536 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PG11 2277 <br /> t+ SYSTEMS_ <br /> .a <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (209) 467-4661 <br /> ADDRESS <br /> or <br /> O 7707 S, Austin Rd Stockton, CA 95215 <br /> Cr 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 /> uj U.S. Department of Transportation. / A <br /> Able G. 08-29-2024 1:41 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 /> I— <br /> cG ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O <br /> a 4882 McGrath St Suite 320 Ventura, CA 93003 08-29-2024 1:41 PM <br /> In <br /> z Pharm waste 2 gallon waste 8 gallon <br /> Q p coot. wl.X T�narm <br /> l, T <br /> nl. wt.# p coot. wt.q p cant. v t.X <br /> 0 10 38 22 165 <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 /> a-a Anthony Jenkins 08-29-20241:41 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> N NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> LU Anthony Jenkins AJ TS-167 <br /> COMPANY NAME TELEPHONE NUMBER <br /> O <br /> (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> I— 4079 Cherokee Rd Stockton CA 95215 08-30-2024 4:36 PM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> O X cont, wt.X p cool. vrt.q p cool, wt.p p coot, wl.p p coot. wt.N <br /> F 10 38 22 165 <br /> Q <br /> 1-- 1 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 /> Ln <br /> w falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> ul <br /> Anthony Jenkins 08-30-2024 4:36 PM <br /> cc NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> I <br /> r COMPANY NAME TELEPHONE NUMBER <br /> Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> < 4800 E Lincoln Ave Fowler CA 93625 <br /> LL <br /> cc, PERMIT NUMBER 7DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 9-05-2024 8:51 AM 203.00 <br /> In <br /> z Q DISCREPANCY INDICATION SPACE <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 /> 2 requirements outlined in that authorization. <br /> Jorge A 09-05-2024 8:51 AM <br /> f 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 />