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Regulated Medical Waste <br /> PagffRAmtI1GDOCUMENT# 7425467 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> I ; <br /> .,•.;, SYSTEMS s <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (20)) 467-4661 <br /> ADDRESS <br /> p 7707 S. Austin Rd Stockton, CA 95215 <br /> I— <br /> or I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br /> Wpackaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br /> � U.S. Department of Transportation. <br /> Able G. 10-10-2024 2:13 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 /> H <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> CL_0 4882 McGrath St Suite 320 Ventura, CA 93003 10-10 2024 2:13 PM <br /> to <br /> z Pharm waste 2 gallon T!Pjharm <br /> t. waste 8 gallon <br /> Q q rant. wt.q vrt,p p cons. wt.N q cant. wt.q q mnl, wt,p <br /> Cr7 20 13 150 <br /> r 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 /> 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 10-10-2024 2:13 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> 177 <br /> 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 /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> I— 4079 Cherokee Rd Stockton CA 95215 10-10-2024 5:49 PM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> O q Cont. 7 wt.a 20 q cant. 13 wt.a 150 q cant. wt.p q cant. wt.q p cunt. wt.q <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 /> Cr 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 /> Anthony Jenkins 10-10-2024 5:49 PM <br /> Cr <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> I— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> < 4800 E Lincoln Ave Fowler CA 93625 <br /> w <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> L- TSOST-89 10-17-2024 4:49 PM 170.00 <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 /> g requirements outlined in that authorization. <br /> I— <br /> LUJorge 10-17-2024 4:49 PM <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 />