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• e Regulated Medical Waste MANIFESTJI 1454578 MedCODE AREA Waste UN3291, Regulated Medical Waste, 5727 MANAGEMENT Safetli,HellabnitV&CotnuNaace n.os.,6.2, PGII TELEPHONE NUMBER COMPANY NAME Windsor Elm Haven Care Center and SubAcute-5727 {209)477-4817 ADDRESS p 6940 Pacific Ave Stockton,CA 95207 � I certify that the information provided is true and correct,and that the generated materials are properly classified,described, Uj Z packaged,labeled/placarded;and are in proper condition for transportation according to the applicable regulations of the LU U.S.Department of Transportation. 04-18-2019 elmhaven NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE O F REPRESENTATIVE GATE NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITTIIAALS REGISTRATION NUMBER Frank Rodriguez TELEPHONE NUMBER COMPANY NAME (866)254-5105 or w MedWaste Management ~Rx DATE MEDICAL WASTE COLLECTED ADDRESS 0 5850 W 3rd Street STE 331 Los Angeles,CA 90036 @4.18-2019 C. tA ¢ r cool, m.r R catt vN R R coli. wt.Y R mrx. wt.R m cmx. wt.r CC F y. I certify that the information provided above is true and correct and that only untreated medical wastes are contained in this Toad.1 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. ¢ 04-18.2019 CL Frank Rodriguez DATE NAME Of COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE REGISTRATION NUMBER TRANSFER STATION: NAME ev NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Frank Rodriguez FR TS-122 TELEPHONE NUMBER COMPANY NAME aMedWaste Management's Hayward Transfer Station (866)254-5105 Z ADDRESS DATE MEDICAL WASTE COLLECTED 2209 American Ave.Unit#6 Ha and CA 94545 04.19-2019 0r r coM. wl R R[ono wt.R r com. wt./ R coM. wt.Y R mol. wL R r NI certify that the information provided above is true and correct and that only U0jEUtQd medical wastes are contained in this load.I am aware that oc falsification of this manifest may result in forfeiture of my transporters registration and/or the privilege of utilizing State authorized facilities. Uj frank 04-19-2019 Iz NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TELEPHONE NUMBER COMPANY NAME HealthWise Services (559)834-3333 >- PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED TOTAL WEIGH�DEPOSrTED/UNLOADED TSOST-89 04-19-2019 DISCREPANCY INDICATION SPACE Z LU t— ui 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 °C requirements outlined in that authorization. 04-19.2019 Dave NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency,call( 866 1254-5105 (24-hr company or other emergency response group telephone)