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Regulated Medical Waste <br /> Pagl€RAae NG DOCUMENT e 8564504 <br /> CODE AREA <br /> UN3291, Regulated Medical Waste, n.o,s., 6.2, PGII 2277 <br /> ,W A S T E <br /> SYSTEMS <br /> r' <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 /> t� ^ � � � <br /> Marcelino M. rV"LJ 07-17-2025 2:26 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 /> Med-Waste Systems, LLC (818) 998 5533 <br /> cY ADDRESS DATE MEDICAL WASTE COLLECTED <br /> a- 4882 McGrath St Suite 320 Ventura, CA 93003 07-17-2025 2:26 PM <br /> Ln <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> Q p cont. wt.p p cont. VA.p p cant. wt.p p cont. wt.p p cont. VA.p <br /> 1 18 1 5 <br /> H <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 07-17-2025 2:26 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> r'4 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 /> a- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> Z ADDRESS <br /> DATE MEDICAL WASTE COLLECTED <br /> cc <br /> I- 4079 Cherokee Rd Stockton CA 95215 07-17-2025 3:02 PM <br /> z Pharm waste 8 gallon Pharm waste 2 gallon <br /> O p Cont. 1 18 1 5 Wt.p Wt.p p cont. vrt.p p Cont. wt.p p cont. wt.p p cont. <br /> Q <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 /> LL <br /> un <br /> Anthony Jenkins 07-17-2025 3:02 PM <br /> cc F- I NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> > COMPANY NAME TELEPHONE NUMBER <br /> F- Healthwise Services J (559) 834-3333 <br /> V ADDRESS <br /> LL 4800 E Lincoln Ave Fowler CA 93625 <br /> w <br /> cc PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> LL TSOST-89 07-24-2025 8:01 AM 23.00 <br /> to <br /> Z Q DISCREPANCY INDICATION SPACE <br /> cr <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 /> 2i requirements outlined in that authorization. <br /> LU Jorge A — 07-24-2025 8:01 AM <br /> cc <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 />