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Regulated Medical Waste <br /> PagGRA(WNG DOCUMENT 4 7818618 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> SYSTEMS <br /> Ii <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (209) 467-4661 <br /> ADDRESS <br /> cc <br /> p 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 /> uj U.S. Department of Transportation. <br /> Marcelino M, ����^� �� 01-16-2025 1:08 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 /> I­_ <br /> orADDRESS DATE MEDICAL WASTE COLLECTED <br /> 0 4882 McGrath St Suite 320 Ventura, CA 93003 01-16-2025 1:08 PM <br /> a <br /> to <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> Q k cont. wt.4 k cant. wt.A q cant. wL k k cant, wt.p p coat. wt.N <br /> 6 82 2 7 <br /> I-- <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 /> Anthony Jenkins 01-16-2025 1:08 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 /> O COMPANY NAME TELEPHONE NUMBER <br /> (Stockton) Med-Waste Systems, LLC (818)'998-5533 <br /> z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> cc <br /> F_ 4079 Cherokee Rd Stockton CA 95215 01-16-2025 5:08 PM <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> 0 N cant. wt.N A cant. wt.A q coot. WI.p p coot. wt.p p cant. WI.A <br /> I— 6 82 2 7 <br /> PI 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 /> lr falsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> w <br /> LL <br /> Anthony Jenkins 01-1 6-2025 5:08 PM <br /> ~ NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> 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 /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 01-23-2025 8:24 AM 89.00 <br /> to <br /> z Q DISCREPANCY INDICATION SPACE <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 /> :2 requirements outlined in that authorization. <br /> F- <br /> w Jorge 01-23-2025 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 />