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Regulated Medical Waste <br /> PageRAcANG DOCUMENT H 8219080 <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> WASTE <br /> SYSTEMS <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (2I 467-4661 <br /> ADDRESS <br /> O 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 /> 0 U.S. Department of Transportation. <br /> Marcelino M. 04-24-2025 11:00 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 /> w Med-Waste Systems, LLC (818) 998-5533 <br /> I— <br /> cr ADDRESS DATE MEDICAL WASTE COLLECTED <br /> a <br /> 4882 McGrath St Suite 320 Ventura, CA 93003 04-24 2025 11:00 AM <br /> to <br /> z Pharm waste 8 gallon Pharm waste 18 gallon <br /> Q M Cont. wt.q q cont. vrt.q q coot. wt.N q cont. wt.q <br /> H 2 33 1 14 <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 /> _:E <br /> c Anthony Jenkins bo 04-24-2025 11:00 AM <br /> n- <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 /> Uj Anthony Jenkins AJ TS-167 <br /> tz COMPANY NAME O TELEPHONE NUMBER <br /> (Stockton) Med-Waste Systems, LLC (818) 998 5533 <br /> z ADDRESS <br /> cr DATE MEDICAL WASTE COLLECTED <br /> t- 4079 Cherokee Rd Stockton CA 95215 04-24-2025 2:32 PM <br /> z Pharm waste 8 gallon Pharm waste 18:pa:llonO q cunt. wt q q cant t . vrt.q q cont, wI.N K coot. wt.q <br /> FZ 2 33 1 <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 /> 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 /> Anthony Jenkins 04-24-2025 2:32 PM <br /> H NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> r COMPANY NAME TELEPHONE NUMBER <br /> F- Healthwise Services (559) 834-3333 <br /> V ADDRESS <br /> w 4800 E Lincoln Ave Fowler CA 93625 <br /> w PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED747.00 <br /> TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w TSOST-89 05-01-2025 8:05 AM <br /> to <br /> Z Q DISCREPANCY INDICATION SPACE <br /> cc <br /> t— <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 /> g requirements outlined in that authorization. <br /> Uj Jorge A 05-01-2025 8:05 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 />