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Regulated Medical Waste <br /> PagtFRk,MNG DOCUMENT 4 8335186 <br /> UN3291 , Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> •- •' SYSTEMS ; <br /> P_l <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 /> F <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 /> Marcelino M J 05-22-2025 1:38 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 /> H <br /> cc: ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 0 4882 McGrath St Suite 320 Ventura, CA 93003 05-22-2025 1:38 PM <br /> a <br /> z Pharm waste 8 gallon <br /> Q 4 rant. wt.q q coot. wt.q ✓I Cont. wt q N cont. wt.k q Cont. wt.p <br /> CC 11 130 <br /> t— <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 /> CL a Anthony Jenkins 05-22-2025 1:38 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 /> I-- Anthony Jenkins AJ TS-167 <br /> O COMPANY NAME TELEPHONE NUMBER <br /> (L (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> z <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Cc <br /> F— 4079 Cherokee Rd Stockton CA 95215 05-22-2025 3:45 PM <br /> z Pharm waste 8 gallon <br /> Q p coot. wI.p N Cont. wt tl p mot. wt.N k cont. w(.p p cant. wt.B <br /> 1= 11 130 <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 /> 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 /> LL <br /> QAnthony Jenkins 05-22-2025 3:45 PM <br /> F cc NAM E OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> - <br /> } 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 /> w <br /> PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w TSOST-89 05-29-2025 7:56 AM 130.00 <br /> to <br /> z Q DISCREPANCY INDICATION SPACE <br /> E— <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 /> w Jorge a - 05-29-2025 7:56 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 />