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Regulated Medical Waste <br /> PageRAaANGDOCUMENT# 8651868 <br /> x UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII 2277 CODE AREA <br /> sir .•WASTE <br /> SYSTEMS <br /> 1' <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 /> H <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 /> Able G U /w 08-07-2025 1:57 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 /> cc w Med-Waste Systems, LLC (818) 998 5533 <br /> 1-- <br /> cc ADDRESS DATE MEDICAL WASTE COLLECTED <br /> a- <br /> a 4882 McGrath St Suite 320 Ventura, CA 93003 08-07-2025 1:57 PM <br /> z Pharm waste 8 gallon <br /> ¢ 4 cant. wt.p p cool. vR.N q cant. wt,q W cunt. wt.p B coot. VA.M <br /> H <br /> 11 118 <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 /> cc Anthony Jenkins 08-07-2025 1:57 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 /> uj Anthony Jenkins AJ TS-167 <br /> cc COMPANY NAME TELEPHONE NUMBER <br /> a- (Stockton) Med-Waste Systems, LLC (818) 998-5533 <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> I 4079 Cherokee Rd Stockton CA 95215 08-07-2025 2:43 PM <br /> z Pharm waste 8 gallon <br /> ['] 4 cant. wt.p #cant. w[.M p mot. wt.N p mot. Wt.p k cant. wt.p <br /> P 11 118 <br /> UP 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 /> aAnthony Jenkins 08-07-2025 2:43 PM <br /> NAME OF COMPANY REPRESENTATIVE (Print) SIGNATURE OF REPRESENTATIVE DATE <br /> } COMPANY NAME TELEPHONE NUMBER <br /> I— Healthwise Services (559) 834-3333 <br /> J <br /> V ADDRESS <br /> w 4800 E Lincoln Ave Fowler CA 93625 <br /> is PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPOSITED/UNLOADED <br /> w <br /> LL TSOST-89 08-14-2025 8:05 AM 118.00 <br /> to <br /> z DISCREPANCY INDICATION SPACE <br /> or <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 /> t— � <br /> w Jorge A 08-14-2025 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 />