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Regulated Medical Waste <br /> PagGRAc*IG DOCUMENT u 7398160 <br /> CODE AREA <br /> I UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> AST E <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 /> or 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 transportation according to the applicable regulations of the <br /> Lu U.S. Department of Transportation. <br /> Able G. c� 10-03-2024 2:18 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 Mod-Waste Systems, LLC (818) 998-5533 <br /> I— <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O 4882 McGrath St Suite 320 Ventura, CA 93003 10-03-2024 2:18 PM <br /> a <br /> z Pharm waste 2 gallon71Pharm waste 8 gallon <br /> < 4 cant. wt.p cant. vrt.4 q Cont. wt.4 4 cant. wt.4 4 coot, vrt.p <br /> or 2 9 8 97 <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 /> a <br /> Anthony Jenkins 10-03-2024 2:18 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 /> N (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z <br /> cc ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Icc <br /> 4079 Cherokee Rd Stockton CA 95215 10-04-2024 12:39 PM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> O 4 cant, 2 wL p 9 4 cant. 8 wt.4 97 4 cant. wt.4 4 cont. wt.4 N cant. wt.4 <br /> H <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 falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> cAnthony Jenkins 10-04-2024 12:39 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r COMPANY NAME TELEPHONE NUMBER <br /> Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> u 4800 E Lincoln Ave Fowler CA 93625 <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LU <br /> w TSOST-89 10-10-2024 10:00 AM 106.00 <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 /> 2 requirements outlined in that authorization. <br /> F- <br /> w Jorge Ambriz <== 10 10 2024 10:00 AM <br /> I 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 />