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Regulated Medical Waste <br /> PageRAafING DOCUMENT# 7714011 <br /> CODE AREA <br /> �i UN3291, Regulated Medical Waste, n.o.s., 6,2, PG11 2277 <br /> SYSTEMS J <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.1 U.S. Department of Transportation. <br /> Marcelino M, �lf'��- 12-19-2024 2:32 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 /> Q_a 4882 McGrath St Suite 320 Ventura, CA 93003 12-19-2024 2:32 PM <br /> z Pharm waste 8 gallon <br /> Q a cant. wt.a a coot. wt.q p coot. wt.p a cant. wl.a p coot. wt.a <br /> � 0 0 <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 /> a <br /> Anthony Jenkins 12-19-2024 2:32 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 /> Uj Anthony Jenkins AJ TS-167 <br /> COMPANY NAME TELEPHONE NUMBER <br /> (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Q <br /> 4079 Cherokee Rd Stockton CA 95215 12-19-2024 3:50 PM <br /> z Pharm waste 8 gallon <br /> 0 R cant. wt.# FN-nt <br /> wt.a 71q coot. wt.q TN <br /> coot. wt.q7Tont. wL p <br /> I— 0 0 <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 /> cc 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 /> Anthony Jenkins 1 2-1 9-2024 3:50 PM <br /> H <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r COMPANY NAME TELEPHONE NUMBER <br /> F Healthwise Services (559) 834-3333 <br /> J <br /> v ADDRESS <br /> 4800 E Lincoln Ave Fowler CA 93625 <br /> L= PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> U_ TSOST-89 12-26-2024 7:52 AM <br /> N <br /> z DISCREPANCY INDICATION SPACE <br /> Q <br /> I— <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 /> :�E requirements outlined in that authorization. <br /> F_ <br /> w Jorge 12-26-2024 7:52 AM <br /> i 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 />