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Regulated Medical Waste <br /> MedMANIFEST# 1623383 <br /> CODE AREA <br /> Waste UN3291, Regulated Medical Waste, 5727 <br /> MANAGEMENT <br /> Safety, <br /> Sellablityacompliance II.O.s.,6.2, PG11 <br /> COMPANY NAME TELEPHONE NUMBER <br /> Windsor Elm Haven Care Center and SubAcute-5727 (209)477-4817 <br /> ADDRESS <br /> p 6940 Pacific Ave Stockton,CA 95207 <br /> � I certify that the Information provided is true and correct,and that the generated materials are properly classified,described, <br /> Zpackaged,labeled/placarded;and are in proper condition for transportation according to the applicable regulations of the <br /> Z <br /> LU U.S.Department of Transportation. <br /> Julio 08-05-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> Pao Saechin PS 5633 <br /> COMPANY NAME TELEPHONE NUMBER <br /> Cr W MedWaste Management (866)254-5105 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 0 5850 W 3rd Street STE 331 Los Angeles,CA 90036 08-05-2019 <br /> Ln Pharm Waste-5 Gal Pharm Waste-2 Gal <br /> <Q owl. YR/ Y Cont. 4 Wt.Y Y CCnt W7.Y Y cmfi. WI.I A con{. W,.1 <br /> I certify that the information provided above is true and correct and that only untrealgd medical wastes are contained in this load.I am aware that <br /> q falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> a Pao Saechin 0"5-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIG N ATV RE O F REPRESENTATIVE DATE <br /> TRANSFER STATION: NAME REGISTRATION NUMBER <br /> ry NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER <br /> w Pao Saechin PS TS-122 <br /> a COMPANY NAME TELEPHONE NUMBER <br /> 0- MedWaste Management's Hayward Transfer Station (866)254.6105 <br /> Z ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 2209 American Ave.Unit#6 Hayward CA 94545 1 08-05-2019 <br /> z Pharm Waste;5 Gal Pharm Waste-2 Gal <br /> Y cont wR.R YcotN. I... WI.Y Ymnt. w4Y 0Cm11. wt.Y <br /> 9 0 4 0 <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 manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> Lu <br /> LL Y--� <br /> Z Rao Saechin 08-05-2019 <br /> F NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> COMPANY NAME TELEPHONE NUMBER <br /> HeaithWise Services (559)834-3333 <br /> <br /> <br /> —� PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED 71�TOTAL WEIGHT DEPOSITED/UNLOADED <br /> TSOST-89 08-06-2019 <br /> LL <br /> F DISCREPANCY INDICATION SPACE <br /> Z <br /> Lu <br /> I^ <br /> w 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 /> Cr. requirements outlined in that authorization. <br /> David Telles O 08-06-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> In case of emergency,call( 866 ) 254-5105 (24-hr company or other emergency response group telephone) <br />