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Regulated Medical Waste <br /> PageRAc+a1tNG DOCUMENT s 7683168 <br /> r <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> t rf ni ,':Wo` STE <br /> ` 2, 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 /> F- <br /> cc 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. <br /> Marcelino M. 1 2-1 2-2024 2:44 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 /> Cr w Med-Waste Systems, LLC (818) 998-5533 <br /> cc ADDRESS DATE MEDICAL WASTE COLLECTED <br /> d <br /> 4882 McGrath St Suite 320 Ventura, CA 93003 12-12-2024 2:44 PM <br /> z Pharm waste 8 gallon <br /> Q p coot. w6 X q mot. vA.p q coot. wt.p p coot, wt.N p coot. vR.q <br /> cr 12 143 <br /> F- <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 Anthony Jenkins 12-12-2024 2:44 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> ry NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> cc ui <br /> Anthony Jenkins AJ TS-167 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> LA (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> I 4079 Cherokee Rd Stockton CA 95215 12-12-2024 4:20 PM <br /> z Pharm waste 8 gallon <br /> 0p coot. wt.p p coot. wt.p M coot, wt.p p coot, wl.p tl cont. wt.k <br /> 12 143 <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 /> 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 /> QAnthony Jenkins ` 12-12-2024 4:20 PM <br /> I'_ NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r COMPANY NAME TELEPHONE NUMBER <br /> I Healthwise Services (559) 834-3333 <br /> _I <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 /> w TSOST-89 12-19-2024 8:24 AM 143.00 <br /> Z Q DISCREPANCY INDICATION SPACE <br /> K <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 /> w Jorge 12-19-2024 8:24 AM <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 />