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Regulated Medical Waste <br /> PagffRAaANG DOCUMENT N 7483066 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <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 /> cr 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 /> Uj U.S. Department of Transportation. <br /> Able G. y 10-24-2024 12:40 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 /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O 4882 McGrath St Suite 320 Ventura, CA 93003 10-24-2024 12:40 PM <br /> a <br /> Z Pharm waste 8 gallon Pharm waste 2 gallon <br /> Q cont. wt.# #coot. wt.# q coot, wt.# #coot. wt.# #cont. wt.# <br /> x 13 168 3 9 <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 /> 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 /> � Anthony Jenkins 10-24-2024 12:40 PM <br /> EL <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 /> E COMPANY NAME TELEPHONE NUMBER <br /> O <br /> a- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> Z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 1— 4079 Cherokee Rd Stockton CA 95215 10-24-2024 2:02 PM <br /> Z Pharm waste 8 gallon Pharm waste 2 gallon <br /> O #cont. 13 168 3 wt.# #cont wt.# #cont. wt.# #coot, wt.# #cont. wt.# <br /> H 9 <br /> F¢ <br /> N 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 10-24-2024 2:02 PM <br /> cc NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> F- <br /> } COMPANY NAME TELEPHONE NUMBER <br /> F_ Healthwise Services (559) 834-3333 <br /> J <br /> U ADDRESS <br /> LL 4800 E Lincoln Ave Fowler CA 93625 <br /> W PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 10-31 2024 IA 1 AM 177.00 <br /> Z DISCREPANCY INDICATION SPACE <br /> Q <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 /> wF- 10-31-20248:11 AM <br /> Jorge A <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> In case of emergency, call ( 818 ) gg8-5533 (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 />