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Regulated Medical Waste <br /> PagffRANNG DOCUMENT# 7845687 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, mo.s., 6.2, PGII 2277 <br /> ' SYSTEMS , <br /> I:a <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 /> I certify that the information provided is true and correct, and that the generated materials are properly classified, described, <br /> Wpackaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br /> LU U.S. Department of Transportation. �1 �' <br /> Marcelino M. ^ 1J 01-23-2025 1:55 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 Mod-Waste Systems, LLC (818) 998-5533 <br /> H <br /> tY ADDRESS DATE MEDICAL WASTE COLLECTED <br /> � 4882 McGrath St Suite 320 Ventura, CA 93003 01-23-2025 1:55 PM <br /> In <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> ¢ A cant. wl.N q coot. wI.9 T <br /> mot. M.k N cant. wt.N M cant, v/t.d <br /> F- <br /> 9 120 11 40 <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 /> Qfalsification of this tracking document may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> cc a Anthony Jenkins dC/ 01-23-2025 1:55 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> 775 <br /> STATION: NAME REGISTRATION NUMBER <br /> r\1 NAME(S) OF PERSONS COLLECTING, TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> Uj Anthony Jenkins AJ TS-167 <br /> EC COMPANY NAME TELEPHONE NUMBER <br /> o- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> 2 ADDRESS DATE MEDICAL WASTE COLLECTED <br /> I— 4079 Cherokee Rd Stockton CA 95215 01-24-2025 1:14 PM <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> Q p coot. wl.p p coot. VA.p q mot. wt.q k coot. wt.p Y coot. VA.p <br /> P 9 120 11 40 <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 /> cc 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 /> Ln <br /> Anthony Jenkins 01-24-2025 1:14 PM <br /> F <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r COMPANY NAME TELEPHONE NUMBER <br /> I— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> U_ 4800 E Lincoln Ave Fowler CA 93625 <br /> CC: PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w <br /> LL TSOST-89 01-30-2025 8:42 AM 160.00 <br /> z 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 /> �E requirements outlined in that authorization. <br /> F- <br /> LU Jorge 01-30-2025 8:42 AM <br /> F' NAME OF COMPANY REPRESENTATIVE (Print) SIG N ATURE 0 F REPRESEN TATIVE 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 />