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Regulated Medical Waste <br /> MANIFEST B 1574975 <br /> MedCODE AREA <br /> Waste UN3291, Regulated Medical Waste, 5727 <br /> MANAGEMENT PGII <br /> SafeNReliability scampiiance n.O.S.,6.2, <br /> FCOMPANY NAME TELEPHONE NUMBER <br /> Windsor Elm Haven Care Center and SubAcute-5727 (209)477-4817 <br /> ADDRESS <br /> 6940 Pacific Ave Stockton,CA 95207 <br /> 0 <br /> F 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 /> Julio _:Ej,. 07-04-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> Frank Rodriguez FR 5633 <br /> COMPANY NAME TELEPHONE NUMBER <br /> LU LU MedWaste Management (866)254-5105 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> ® 5850 W 3rd Street STE 331 Los Angeles,CA 90036 07-04-2019 <br /> a. <br /> z Pharm Was�_, t Pharm Waste-8 Gai Pharm Wast®-2 Gai Pharm Waste-18 Gal Bio Waste-44 Gal <br /> [NM, P[MN. 4 wt.I ® #com5 ® 1 ® 1 Wt.® 0 <br /> cc 16 <br /> I certify that the information provided above is true and correct and that only UntLealed medical wastes are contained in this load.I am aware that <br /> cc falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> i <br /> Frank Rodriguez 07.04.2019 <br /> a — <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> ry NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> W Frank Rodriguez <br /> FR TS-122 <br /> it COMPANY NAME TELEPHONE NUMBER <br /> d 866 254.5105 <br /> 0- MedWaste Management's Hayward Transfer Station ( D <br /> Z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> Q <br /> 2209 American Ave.Unit#6 Hayward CA 94545 07-05-2019 <br /> Z Pharm Waste-5 Gat I Pharm Waste-8 Gal Pharm Waste-2 Gal Pharm Waste-18 Gal Blo Waste-44 Gal <br /> {� /GOM. 16 wt.t® kCoal. 4 YR.@ ® ttOM. 5 W{,I ® /CaN.1 M.® tCoot.1 xt.B 0 <br /> 17, 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 manifest may result in forfeiture of my iransporter's registration a privilege of utilizing State authorized facilities. <br /> Frank 07.05.2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> COMPANY NAME TELEPHONE NUMBER <br /> HealthWlse Services (559)834-3333 <br /> <br /> <br /> M PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED=TOTALPOSITED/UNLOAD D <br /> TSOST-89 07.05-2019 <br /> � DISCREPANCY INDICATION SPACE <br /> Z <br /> w <br /> H <br /> w I certify that 1 have been authorized to accept untreated medical wastes and that 1 have received the above Indicated wastes in accordance with the <br /> or <br /> requirements outlined in that authorization. <br /> erik 07-05.2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> In case of emergency,call( 866 1254-5105 (24-hr company or other emergency response group telephone) <br />