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Regulated Medical Waste PageRAc*IGDOCUMENTs 7510760 CODE AREA UN3291, Regulated Medical Waste, n.o.s., 62, PGII 2277 WASTE" SYSTEMS COMPANY NAME TELEPHONE NUMBER CHCF-California Heath Care Facility (209) 467-4661 ADDRESS cc p 7707 S. Austin Rd Stockton, CA 95215 F- cc I certify that the information provided is true and correct, and that the generated materials are properly classified, described, z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the LU U.S. Department of Transportation. Able G. y 10-31-2024 12:17 PM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Anthony Jenkins AJ 5039 COMPANY NAME TELEPHONE NUMBER cc w Med-Waste Systems, LLC (818) 998-5533 I-_ cc ADDRESS DATE MEDICAL WASTE COLLECTED 0 4882 McGrath St Suite 320 Ventura, CA 93003 10-31-2024 12:17 PM a to z Pharm waste 8 gallon Fnarm waste 2 gallon Q #cant. wt.A vrt.# Aco�l. wt.q #coot, Vt.# #coot. vR.p cc 5 64 1 3 F- > 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 Q falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. a Anthony Jenkins AO— 10-31-2024 12:17 PM NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER N NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Uj ul F O COMPANY NAME TELEPHONE NUMBER d Z Q ADDRESS DATE MEDICAL WASTE COLLECTED cc H O p cant. wt.p #cant. wt.# #Cont. wt.p #Cont. wt.# #cant. wl,q 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 cc falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. w tL [n Z cc NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE } COMPANY NAME TELEPHONE NUMBER I— Healthwise Services (559) 834-3333 J U ADDRESS < 4800 E Lincoln Ave Fowler CA 93625 LL PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED LL TSOST-89 10-31-2024 3:02 PM 67.00 to Z Q DISCREPANCY INDICATION SPACE H F- 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 w requirements outlined in that authorization. w Jorge Ambriz ��— 10-31-2024 3:02 PM F NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency, call ( 818 ) 998-5533 (24-hr company or other emergency response group telephone) Certificate of Destruction: Med-Waste Systems, LLC certifies that the material listed above is treated in accordance with applicable local, state, and federal regulations.