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Barnett Medical Se s Inc 51 o442g 9911 Ph Date: tab'(18,� <br /> mlv ! <br /> 30620 San Antonio S Manifest#. 411 <br /> 51 Q-429-9914 Fax2292 <br /> Hayward Ca 94544 Customer# <br /> EPA#CAL000331285 <br /> TransporterlD#4891 <br /> Generator: Contact: <br /> In 2 ;n - Stockton - ovens aft 121x ' <br /> Frequency of Service <br /> St.)bi,'tor, .a d �.; Pricing - <br /> .i, <br /> a Transfer Facility: X Deetinalion Facilft,) ri AltwollaTransfer Fadity a Destina6lon Fa ity -Y Alternate Destination Facilitya Alternate Transfer Facility <br /> Barnalt Medcal8 ,inc Same4l Medical Se s,ir llhMse Services Photo Waste R <br /> ;acyclirig Incmitis Bay Energy Dattiels Sharpsmart <br /> 306M Son Antonio St 2355 Arch Rd 92 4500 S,LincolnAve 2980 Kemor Blvd#G 3200 Hawidna Point Rd 4144 E Therese Ave <br /> H&jwrd CA 94544 Stockton DA 95215 Fowler CA 93625 San Raul CA 94841 Botlirrve MD Fresm CA 93725 <br /> (610)42"Mi (510)429-9911 55 34-3333 (415) 07 g410)$54-3228, 659-834-8252 <br /> Permit#TS-87 Permit#TSIOST:106 Permit#TS-89 Permit#PWR 122764 Permit#2005-WMI-0036 Permit#TS/OST-55 <br /> Date Date <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG ii <br /> Sharps Containers Regulated Medical Waste Pharmaceutical Trace Chemotheraay' <br /> Size Qty; Size Qty: Wt Size Qty Wt: Size Qty: Wt <br /> Up to: 3 gal <br /> 2gal 20 gal 8gal 12 gal <br /> 4 gal 38 gal 9 gal 18 gal <br /> 6gal 40 gal 12 gal 20 gal, <br /> 8gal 44 gal 18 gal 38 gal <br /> 12 gal Weight <br /> 18 gal Size Qty Weight Product Delivered <br /> Weight: Pathogen: Item# Description: Qt: <br /> Dental Waste: <br /> AmaIgam;Size Qty Fixe r:Size Qty Developer:Size Qty f <br /> Lead:Size Qt Other:Size Qt <br /> Other:Type Size Qt <br /> Notes: ,.,. <br /> Generator Certification: I herebycertify that the contents ofthis consignmentare fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all aspects in proper condition for transport according to <br /> applicable government regulations. <br /> I further declare that this shipment of waste is free of hazardous and mercuryf taste'as defined by the US'code of fecl7r'al <br /> regulations and/or appropriate state rules and regulations, <br /> r' x' ; r <br /> Generator(Customer) <br /> Name of authorized person(print) - Signature Di e 'r <br /> Route Driver <br /> Name of authorized person(print) Signature Date' <br /> Certificate of Destruction <br /> Incineration Name of authorized person(print) Signature Date <br /> Certificate of Destruction <br /> Autoclaved Name of authorized person(print) Signature Date <br />