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Regulated Medical Waste <br /> PagfgRA®11NG DOCUMENT q 8136261 <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> SYSTEMS <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 /> U.S. Department of Transportation. <br /> Able G. 04-03-2025 1:15 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 /> LU <br /> Mod-Waste Systems, LLC (818) 998-5533 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> a 4882 McGrath St Suite 320 Ventura, CA 93003 04 03-2025 1:15 PM <br /> to <br /> z Pharm waste 2 gallon Pharm waste 18 gallon Pharm waste 8 gallon :[aChe (trace) waste <br /> < A conk. wk q 4 conk. vR.N char wt.R o wt.A q cool. vrt,A <br /> 5 30 3 61 6 110 1 2 <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 /> cr <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 Anthony Jenkins 04-03-2025 1:15 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 /> Lu Anthony Jenkins AJ TS-167 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> CL (Stockton) Med-Waste Systems, LLC (818) 998 5533 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> of <br /> 1-- 4079 Cherokee Rd Stockton CA 95215 04-03-2025 1:18 PM <br /> z Pharm waste 2 gallon Pharm waste 18 gallon Pharm waste 8 gallon Chemo (trace) waste <br /> 0 4 conk. wt.A A cant. wt.# #conk. wt.tl A coot. wt.A —TIC <br /> oot. wL N <br /> Q 5 30 3 61 6 110 1 2 <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 /> QAnthony Jenkins 04-03-2025 1:18 PM <br /> cr <br /> cr <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r <br /> COMPANY NAME TELEPHONE NUMBER <br /> Healthwise Services (559) 834-3333 <br /> J <br /> U ADDRESS <br /> < 4800 E Lincoln Ave Fowler CA 93625 <br /> LL <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADEDw <br /> TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 04-10-2025 9:38 AM 203.00 <br /> to <br /> Z Q DISCREPANCY INDICATION SPACE <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 /> requirements outlined in that authorization. <br /> F w \� <br /> Yes lee 04-10-2025 9:38 AM <br /> H- 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 />