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, Regulated Medical Waste MANIFEsra 1350702 MedCODE AREA a a laste UN3291, Regulated Medical Waste, 5727 MANAGEMENT safantnenaenmr$iComalfeace n.0.5.,6,2, PGII COMPANY NAME TELEPHONE NUMBER Windsor Elm Haven Care Center and SubAcute-5727 (209)477-4817 ADDRESS ® 6940 Pacific Ave Stockton,CA 95207 'a I certify that the information provided is true and correct,and that the generated materials are properly classified,described, � packaged,labeled/placarded;and are in proper condition for transportation according to the applicable regulations o the Uj U.S.Department of Transportation. Frank 02-11-2019 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAMES)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INrnALS REGISTRATION NUMBER Mustafa Akbar MA 5633 TELEPHONE NUMBER COMPANYNAME (666)254-5105 W MedWaste Management ADDRESS DATE MEDICAL WASTE COLLECTED ® 5850 W 3rd Street STE 331 Los Angeles,CA 90036 02-11-2019 a Pharm Waste-12 Gal Pharm Waste-2 Gal < r cont7 wt a s a tom. 3 wR.` ® a tom. art.a a cont wn.f acorn wc.a h >- I certify that the information provided above is true and correct and that onlyUnILUted medical wastes are contained 6n this load.I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. "^- 02-11.2019 a Mustafa Akbar DATE NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE TRANSFER STATION; NAME REGISTRATION NUMBER NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS RTS-1 ATION NUMBER a Mustafa Akbar TS-122 Uj Ei COMPANY NAME TELEPHONE NUMBER 2 MedWaste Management's Hayward Transfer Station (866)254.5105 Z ADDRESS DATE MEDICAL WASTE COLLECTED 2209 American Ave.Unit#6 Ha and CA 94545 02-11-2019-- 2-11"2019 z Pharm Waste-12 Gal Pharm Waste-2 Gal rant 7 an.aQ atom. 3 wtr ® oast arta atom. vna aam. at.a I certify that the information provided above is true and correct and that onIyUQtE9djd medical wastes are contained in this load.I am aware that falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. LU muststa 02-11.2019 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TELEPHONE NUMBER COMPANY NAME HealthWise Services 1 (559)834-3333 —, PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGHT DEPO SITED/UN LOADED TSQST-69 02-12-2019 DISCREPANCY INDICATION SPACE Z Lu F- u¢,, i certify that i have been authorized to accept untreated medical wastes and that 1 have received the above indicated wastes in accordance with the t-- requirements outlined In that authorization. Dave 02.12-2019 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency,call i 866 1254-5105 (24-hr company or other emergency response group telephone)