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Regulated Medical Waste Med MANIFEST 1894690 CODE AREA Waste 11N3291, Regulated Medical Waste, 5727 MANAGEMENT Safety,BftbllRv&Cotolance n.o.s.,6.2, PG11 COMPANY NAME TELEPHONE NUMBER Windsor Elm Haven Care Center and SubAcute-5727 (209)477-017 ADDRESS oz 0 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, LU Z packaged,labeled/placarded;and are in proper condition for transportation according to the applicable regulations of the U.S.Department of Transportation. Rolando 01-10-2020 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE NAME(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER Pao Saechin PS 5633 COMPANY NAME TELEPHONE NUMBER wMedWaste Management (866)254-5105 ADDRESS DATE MEDICAL WASTE COLLECTED 0 CL 5850 W 3rd Street STE 331 Los Angeles,CA 90036 01-10-2020 zkn I Pharm Waste;5 Gal Pharm Waste-8 Gal < !cont.t. 0 1 0 IWI I certify that the information provided above Is true and correct and that only 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. P— Pao Saechin 01-10-2020 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE TRANSFER STATION: NAME REGISTRATION NUMBER C-4 NAM E(S)OF PERSONS COLLECTING,TRANSPORTING OR UNLOADING WASTE INITIALS REGISTRATION NUMBER 1= LU Pao Saechin PS TS-122 Si COMPANY NAME TELEPHONE NUMBER 0 V)0. MedWaste Management's Hayward Transfer Station (866)264-5105 Z ADDRESS DATE MEDICAL WASTE COLLECTED 2209 American Ave.Unit#6 Hayward CA 94545 1 01-10-2020 z Pharm Waste;5 Gal Pharm Waste-8 Gal 0 fWnt. 1 L 1!cont. I WLS 1 1.. 1 W1, 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 falsification of this manifest may result in forfeiture of my transporter's registration and/or the privilege of utilizing State-authorized facilities. Uj Z Pao V 01.10-2020 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE COMPANY NAME TELEPHONE NUMBER HealthWlse Services (559)8343333 PERMIT NUMBER DATE WASTE WAS DEPOSITEO/UNLOADED JTOTAL WEIGHT DEPOSITED/UNLOADED TSOST-89 01-142020 < LA- t— DISCREPANCY INDICATION SPACE Z 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 Cr. requirements outlined in that authorization. David Telles 01-14-2020 NAME OF COMPANY REPRESENTATIVE(Print) SIGNATURE OF REPRESENTATIVE DATE In case of emergency,call 66 ) 2546105 (24-hr company or other emergency response group telephone)