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Regulated Medical Waste <br /> PagURA(WNG DOCUMENT# 7792361 <br /> �p }q g ' UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> L 3zIAS1E.—t._ <br /> SYSTEMS °a <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (209) 467-4661 <br /> ADDRESS <br /> cc <br /> 0 7707 S. Austin Rd Stockton, CA 95215 <br /> H <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 /> ui U.S. Department of Transportation. <br /> Marcelino M, l 01-10-2025 12:17 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 /> H <br /> cc ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 0 4882 McGrath St Suite 320 Ventura, CA 93003 01-10-2025 12:17 PM <br /> n. <br /> z Pharm waste 8 gall77, hemo (trace) waste Pharm waste 18 gallon Pharm waste 2 gallonharps 3 gallon <br /> Q X conl. wt.q cont. VA.a q Cont, wt.a a Cont. wt.a a Cont. wt.23 2 1 1 2 43 3 7 1 5 <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 <br /> Anthony Jenkins 01-10-2025 12:17 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 /> w Anthony Jenkins AJ TS-167 <br /> COMPANY NAME TELEPHONE NUMBER <br /> O <br /> N (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Q <br /> Fes- 4079 Cherokee Rd Stockton CA 95215 01-10-2025 2:33 PM <br /> z Pharm waste 8 gallon Chemo (trace) waste Pharm waste 18 gallon Pharm waste 2 gallon Sharps 3 gallon <br /> O a coot. wt N p coot. wt.p Y coot. wt.p a coot. wt.a p coot, wt.p <br /> 23 284 1 1 2 43 3 7 1 5 <br /> 1 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 /> u_ <br /> QAnthony Jenkins 01-10-2025 2:33 PM <br /> tz NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> I— <br /> } COMPANY NAME TELEPHONE NUMBER <br /> )— Healthwise Services (559) 834-3333 <br /> V ADDRESS <br /> 4800 E Lincoln Ave Fowler CA 93625 <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w TSOST-89 01-16-2025 8:19 AM 340.00 <br /> z DISCREPANCY INDICATION SPACE <br /> Q <br /> F_ <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 /> :�i requirements outlined in that authorization. <br /> f— <br /> w Jorge v 01-16-2025 8:19 AM <br /> Cr <br /> t" 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 />