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Regulated Medical Waste <br /> Pag(fRACID11NG DOCUMENT# 8107588 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> t hfa_ <br /> ',.WASTE <br /> E <br /> SYSTEMS <br /> .' <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 /> Z packaged, labeled/placarded; and are in proper condition for transportation according to the applicable regulations of the <br /> Lu U.S. Department of Transportation. <br /> t <br /> Marcelino M. 03-27-2025 2:09 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 /> F— <br /> cC ADDRESS DATE MEDICAL WASTE COLLECTED <br /> m 4882 McGrath St Suite 320 Ventura, CA 93003 03-27-2025 2:09 PM <br /> to <br /> Z Pharm waste 2 gallon Pharm waste 8 gallon <br /> < M cant. 9 wt.a 34 a cant. 8 VA. <br /> n 108 a cant. wt.a a cant. wt.a a cant. Vrt.a <br /> 1 <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 /> Anthony Jenkins 03-27-2025 2:09 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 /> H 1 <br /> Anthony Jenkins AJ TS- 67 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> a- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> F 4079 Cherokee Rd Stockton CA 95215 04-01-2025 4:39 PM <br /> Z Pharm waste 2 gallon Pharm waste 8 gallon <br /> O N cant. 9 wt.tl 34 q cant, 8 wt.k 108 N cant. wt.N #cant. wt.A p cant. VA.N <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 /> 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 /> aAnthony Jenkins 04-01-2025 4:39 PM <br /> F— <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> I— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> < 4800 E Lincoln Ave Fowler CA 93625 <br /> LL <br /> cr PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w <br /> V-to TSOST-89 04-03-2025 7:57 AM 142.00 <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 /> I— <br /> w JORGE AMBRIZ 04-03-2025 7:57 AM <br /> 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 />