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Regulated Medical Waste <br /> PagffRAa*QGDOCUMENT# 7569241 <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 /> Cr 7707 S. Austin Rd Stockton, CA 95215 <br /> 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 /> U.S. Department of Transportation. A / <br /> Able G. 6�l 11-14-2024 2:49 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 /> cc w Med-Waste Systems, LLC (818) 998-5533 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O 4882 McGrath St Suite 320 Ventura, CA 93003 11-14-2024 2:49 PM <br /> a <br /> z Chemo (trace) waste Pharm waste 18 gallon Pharm waste 8 gallon Bio 44 gallon Bio 38 gallon <br /> #cont. wt.# #cont. M.# p mnt. wt.# q coot, wt.# #cont. wt.# <br /> 3 5 1 21 19 203 3 160 8 331 <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 /> 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 14 <br /> Anthony Jenkins 1 1-14-2024 2:49 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 /> t� COMPANY NAME TELEPHONE NUMBER <br /> a (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> to <br /> z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Q <br /> 4079 Cherokee Rd Stockton CA 95215 11-14-2024 2:50 PM <br /> z Chemo (trace) waste Pharm waste 18 gallon Pharm waste 8 gallon Bio 44 gallon Bio 38 gallon <br /> 0 #cons. wt.# #cont. Vn.# #rant. wt.# #cunt. wt.p #cont. wt.# <br /> 1= 3 5 1 21 19 203 3 160 8 331 <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 /> 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 /> QAnthony Jenkins 1 1-1 4-2024 2:50 PM <br /> cc: NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> E— <br /> } COMPANY NAME TELEPHONE NUMBER <br /> Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> LL 4800 E Lincoln Ave Fowler CA 93625 <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 11-21 2024 8:14 AM 740.00 <br /> to <br /> z <br /> Q DISCREPANCY INDICATION SPACE <br /> F— <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 /> 2i requirements outlined in that authorization. <br /> w Jorge 11-21-2024 8:14 AM <br /> 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 />