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Regulated Medical Waste <br /> PagffRAaA0GDOCUMENT# 8304366 <br /> -- CODE AREA <br /> UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 <br /> tlq ,3 ;. WASTE ; <br /> SYSTEMS I ! <br /> i <br /> COMPANY NAME TELEPHONE NUMBER <br /> CHCF-California Heath Care Facility (209) 467-4661 <br /> ADDRESS <br /> cc <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 /> Lu U.S. Department of Transportation. '(/d <br /> Able G L_ � 05-15-2025 10:23 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 Mod-Waste Systems, LLC (818) 998-5533 <br /> I- <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O 4882 McGrath St Suite 320 Ventura, CA 93003 <br /> a. 05-15-2025 10:23 AM <br /> to <br /> z Pharm waste 8 gallon Pharm waste 18 gallon <br /> Q 0 Cont. wt.A R cont, v t.# q coot. wt.p #cont. wl.q 9 cant. VA.B <br /> cc 5 63 101 <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 /> a <br /> Anthony Jenkins 05-15-2025 10:23 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 /> LU <br /> Anthony Jenkins AJ TS 167 <br /> E COMPANY NAME TELEPHONE NUMBER <br /> O <br /> a- (Stockton) Mod-Waste Systems, LLC (818) 998-5533 <br /> Z <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> F_ 4079 Cherokee Rd Stockton CA 95215 05-15-2025 6:55 PM <br /> z Pharm waste 8 gallon Pharm waste 18 gallon <br /> 0 R cant. wt,0 p cont. wt.p N cont. wt.N #cunt. wt.W 4 cont. wt.p <br /> 5 63 101 <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 /> Ln <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 /> Lu <br /> LL <br /> QAnthony Jenkins 05-15-2025 6:55 PM <br /> � NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> f— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> t¢ 4800 E Lincoln Ave Fowler CA 93625 <br /> CC PERMIT NUMBER TDATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w TSOST-89 5-22-2025 7:57 AM 164.00 <br /> z DISCREPANCY INDICATION SPACE <br /> Q <br /> H <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 /> w Jorge A 05-22-2025 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 />