Laserfiche WebLink
3563 Investment Blvd.,Suite 6 <br /> �� TI Hayward,CA 94545 CA T Registration#5997 <br /> Medical & iohazard Waste Disposal Phone:510.265.0742 'fr sport Permit 5997 <br /> Fax:866.409.1963 EPA# CAL000359974 <br /> Customer Information <br /> Name: / Account : 24 HOUR EMERGENCY PHONE: <br /> Address: `� i t;% .h, , x.:; Telephone. <br /> y _ 877.446.8449 <br /> City: a , State Zip: i E Contact: ` <br /> Picked sto err *Check Box for Waste Type <br /> UN 3297, Regulated Medical Waste, n.o.s., 6.2,PG H <br /> Chemotherapy Waste,Pathology Waste art /or Pharmaceutical Waste <br /> rGA <br /> 5 GAL <br /> 8 GAL 10 GAL <br /> 18 GAL Chemo Shar s 12 GAL/BX <br /> 28 GAL 18 GAL <br /> 38 GAL 28 GAL <br /> 96 GAL 38 GAL <br /> t <br /> SUB TOTAL SUB-TOTAL SUB-TOTAL SUB TOTAL SUB TOTAL <br /> 81 na <br /> tures r Compliance wind uhor tions Total Containers: Delivered to r • Containers <br /> by declare that the content of this consignment are 1 further declare that this ahl merit of Total Gross Weight: finer Qite container Q <br /> nd accurately described above by proper ship waste is fres of hazardous and mercury <br /> and are classified,packed,marked,and labeie� wastes as defined by the US'Code of Minus Tare Weight. <br /> in ail aspects in proper condition for transport Federal Regulations and/or app to <br /> ding to applicable government regulations State Rules and Ae utations. Total Piet Lbs U CF U <br /> mer CUSto r: Sign ure: Date: / <br /> not ams ease Sign EM N=9) <br /> acute Opute Driver ,> / i Delivered t Customer - PrePaid <br /> r ver: Ignature. Date: <br /> rensfer a ransfer Drive``f ea gn ame do ner tuantitt► k ount <br /> river: Rgnature: Date: / <br /> easePrint aU Nains) lease Wn EUJ Name <br /> Certificate of Race1pt. Certification of receipt of waste as covered by this manifest number: <br /> Signature Date: / t <br /> Certificate Destructions. Certification of receipt and destruction of waste as covered by this manifest number; Notes,Comments,Modifications or Discrepancies <br /> Signature. Dater/ / <br /> Design #ed Facinky Alternatesin tc Facility Desi n is Incinerator c°t5 <br /> Niime: Daniels Sharpsmart„Inc. Name: Medica Waste Services Name: M ARMC <br /> Address: 4144 E.Therese Ave. Address: 7321 Ouimby'Street Address: 7 HWY 65 <br /> city/State/Zip: Fresno,CA 93725 City/state/zip: Paramount,GA X723 City/State/Zip: A uac,TX 77514 <br /> Phone: 559.834;6252 Phone; 562.529.3700 Phone: 409.267.3.913 , <br /> Permit#: TS/0ST55 I Permit Number:TS/OST-94 Permit : NSW2239-A <br /> White-Certificate of Destruction-Return to Customer Canary-Transporter` Green-File Copy Gold -Customer <br />