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Regulated Medical Waste <br /> PagffRAa4NG DOCUMENT✓✓ 8192314 <br /> CODE AREA <br /> UN3291 , Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <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— <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 /> 1U U.S. Department of Transportation. <br /> Marcelino M A111 Ilk 0111 1' 04-17-2025 11:56 AM <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 /> I-_ <br /> cc ADDRESS DATE MEDICAL WASTE COLLECTED <br /> CL d 4882 McGrath St Suite 320 Ventura, CA 93003 04-17-2025 11:56 AM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> Q q coot. wl,A q coot. wt.M q mot. wt.M q cant wt.d T4 ­ <br /> wl.tl <br /> � 4 11 4 46 <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 /> cc <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 /> CL a Anthony Jenkins / V 04-17-2025 11:56 AM <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 /> Anthony Jenkins AJ TS-167 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> N (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> F 4079 Cherokee Rd Stockton CA 95215 1 04-17-2025 12:40 PM <br /> z Pharm waste 2 gallon Pharm waste 8 gallon <br /> Q N cant. 4 11 4 wt,q #cant. wt.N 46 q mot. Wt.q q cant. wt.b #cant. wt.$ <br /> 1= <br /> Q <br /> � <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 /> cc 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 04-17-2025 12:40 PM <br /> Cr OFOF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> F <br /> r COMPANY NAME TELEPHONE NUMBER <br /> F Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> u 4800 E Lincoln Ave Fowler CA 93625 <br /> ix PERMIT NUMBER —T—DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> u_ TSOST-89 04-24-2025 8:20 AM 57.00 <br /> to <br /> z<C DISCREPANCY INDICATION SPACE <br /> H <br /> I— <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 A > 04-24-2025 8:20 AM <br /> cc <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 />