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Regulated Medical Waste <br /> PagffRAa4NG DOCUMENT n 7283520 <br /> N <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> . MAJTE <br /> SYSTEMS <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 /> E-- <br /> Cr I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br /> "' packaged, labeled/ lacarded; and are in proper condition for transportation according to the applicable regulations of the <br /> z P 9 p p p p 9 pP � 9 <br /> c" U.S. Department of Transportation. <br /> �� ' <br /> Able G. 09-05-2024 1:56 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 /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 0 4882 McGrath St Suite 320 Ventura, CA 93003 09-05-2024 1 :56 PM <br /> a. <br /> z Pharm waste 8 gallon <br /> Q ®Cont. wt.W W cont. M M B coot, wt.k k cont. wt.A p cont. wt.A <br /> � 1 1 12 <br /> F, <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 /> Q 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 09-05-2024 1:56 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 /> Anthony Jenkins AJ TS-167 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> N (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 09-05-2024 3:32 PM <br /> 1 <br /> z Pharm waste 8 gallon <br /> Q k Cont. wt.M N cont. v L k M cont. wt M p Cont, wt.N FInt wt.d <br /> P: 1 12 <br /> Q <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 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 /> LL <br /> QAnthony Jenkins 09-05-2024 3:32 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> Healthwise Services (559) 834-3333 <br /> U ADDRESS <br /> < 4800 E Lincoln Ave Fowler CA 93625 <br /> LL <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 09-12-2024 8:12 AM 12.00 <br /> z Q DISCREPANCY INDICATION SPACE <br /> H <br /> I-- <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 /> :E requirements outlined in that authorization. <br /> F— <br /> w Jorge A 09-12-2024 8:12 AM <br /> H 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 />