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Regulated Medical Waste <br /> MedMANIFEST# 1675631 <br /> CODE AREA <br /> Waste UN3291, Regulated Medical Waste, 5727 <br /> MANAGEMENT <br /> Solety,eellabliltyaCompliance n.o.s., 6.2, PGII <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 /> f° <br /> I certify that the information provided Is true and correct,and that the generated materials are properly classified,described, <br /> Uj <br /> packaged,labeled/placarded;and are in proper condition for transportation according to the applicable regulations of the <br /> Z <br /> "" U.S.Department of Transportation. <br /> L� <br /> Julio ::_ 09-05-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTETPS <br /> ITIALS REGISTRATION NUMBER <br /> Pao Saechin 5633 <br /> COMPANY NAME TELEPHONE NUMBER <br /> LU MedWaste Management (866)254-5105 <br /> ADDRESS DATE MEDICAL WASTE COLLECTED <br /> O 5850 W 3rd Street STE 331 Los Angeles,CA 90036 09-05-2019 <br /> CL <br /> z Bio Waste-44 Gal Pharm Waste-5 Gal Pharm Waste-2 Gal <br /> arcan. 1 It.r 0 rcan. 7 wc.r 0 rcont 1 wtr Q r<oM .n.r rmM w.r <br /> H <br /> > I certify that the Information provided above is true and correct and that onlyuntreated 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 /> a Pao Saechin ^� 09-05-2019 <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 Pao Saechin PS TS-122 <br /> R COMPANY NAME TELEPHONE NUMBER <br /> aMedWaste Management's Hayward Transfer Station (866)254-5105 <br /> Q ADDRESS DATE MEDICAL WASTE COLLECTED <br /> 2209 American Ave.Unit#6 Hayward CA 945451 09-05-2019 <br /> z Bio Waste.44 Gal Pharm Waste-5 Gal Pharm Waste-2 Gal <br /> Q rant. 1 wLr rcont. 7 vett ® r<ax. 1 war ® ®can. wt.r rcwn, wtr <br /> tI certify that the information provided above is true and correct and that only untreated medical wastes are contained in this load.l am aware that <br /> LU falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. <br /> Z pao saechin 09-05-2019 <br /> NAME Of COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> COMPANY NAME TELEPHONE NUMBER <br /> HeaithWise Services (559)834-3333 <br /> <br /> <br /> J PERMIT NUMBER DATE WASTE WAS DEPOSITED/UNLOADED JOTAL WEIGHT DEPOSITED/UNLOADED <br /> ¢ TSOST-89 09-06-2019 <br /> W <br /> F- DISCREPANCY INDICATION SPACE <br /> Z <br /> w <br /> H <br /> LU 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 /> F- requirements outlined in that authorization. <br /> Pablo 09-06-2019 <br /> NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE <br /> In case of emergency,cal( 866 }254-5105 (24-hr company or other emergency response group telephone) <br />