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Regulated Medical Waste <br /> PageRA(WNGDOCUMENT# 7370259 <br /> CODE AREA <br /> I UN3291, Regulated Medical Waste, n.o.s„ 6.2, PGII 2277 <br /> ai zy � ;@(t(ASTE t <br /> is > SYSTEMS a <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 /> cc I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br /> z packaged, labeled/placarded; and are in proper condition for transportations according to the applicable regulations of the <br /> LU U.S. Department of Transportation, <br /> Able G. 09-26-2024 1:37 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 /> Cr ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O <br /> a 4882 McGrath St Suite 320 Ventura, CA 93003 09-26-2024 1:37 PM <br /> to <br /> z Chemo (trace) waste Pharm waste 2 gallon Pharm waste 8 gallon <br /> Q A cunt, wt.B k cont. wt.0 A It <br /> wt.k k cant. wt.p k cent. 4.0 <br /> 12 20 2 8 8 104 <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 n- <br /> Anthony Jenkins 09-26-2024 1:37 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 /> w Anthony Jenkins AJ TS-167 <br /> COMPANY NAME TELEPHONE NUMBER <br /> O <br /> a- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Q <br /> 4079 Cherokee Rd Stockton CA 95215 09-26-2024 4:54 PM <br /> z Chemo (trace) waste Pharm waste 2 gallon Pharm waste 8 gallon <br /> O #cont. wt,W K cont. wt.A k cont. wt.N b cont. wt.# p Cont. wt.# <br /> F= 12 20 2 8 8 104 <br /> NI 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 /> w <br /> LL <br /> QAnthony Jenkins 7 09-26-2024 4:54 PM <br /> F— <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> F- Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> w 4800 E Lincoln Ave Fowler CA 93625 <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> U_ TSOST-89 10-03-2024 8:53 AM 132.00 <br /> to <br /> z DISCREPANCY INDICATION SPACE <br /> Q <br /> cc <br /> F— <br /> F— <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 /> g requirements outlined in that authorization. <br /> F— <br /> w Jorge Ambriz 10-03-2024 8:53 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 />