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From:New Hope Post Acute Care 209 832 2273 17/70/2015 07:33 4015 P.007/014 <br /> Adak Daniels Sharps*Inc. Tel: 559-834-6252 anifest#: 758445 <br /> A 4144 E Therese Ave Fa : ,-834-2242 ustomer*: 1666 -11 <br /> Fresno,CA 93725 <br /> Daniels' For Chemical Emergency Date: Sep 08,2015 <br /> rJ�:mg•w•aern,:,.o S:arar <br /> Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHE:MTREC Day or Night 11111111111111111111l� � <br /> "Wr 1-800-424-9300 7 5 18 4 45 <br /> Penerator: Carrier: Transporter Permits: <br /> ;tate ID No.: Daniels Sharpsmart,Inc. CA-4707 <br /> lew Hope Post Accute Care 111 W Jackson Blvd EPA#CAL000344393 <br /> 586 Buthmann Ave Suite 720 <br /> 'racy CA 953762165 Chicago, IL 60604 US DOT#1295076 <br /> dtri:Dolly Bindra 312-546-8900 <br /> 209)8 Vehicle Decal: <br /> he inatl DTherew <br /> Alternate Destination Facility Transfer Facility: <br /> Dsm Inc. Curtis Bay Energy Daniels-Fresno Plant <br /> 4e A 3200 Hawkins Point Road 4144 East Therese <br /> F725 Baltimore,MO 21226 Fresno CA `93725 TJjJ���^^^���far Receipt Signature a3 Date: <br /> one. 5Phone: 443-692-2300 Phone: � � Cp'e 't#: Permit#: 2005-WMI-0036 Permit A W C_ r V U 1 <br /> -+ear-a �..�®.,..,'�. <br /> 1laste este ' N 3291 Regulated Medical Waste n.o.s 6.2 PG II O <br /> Material Type <br /> y�e- �C Net Wt Tvae O Net Wt. Tvae Net Wt. (Circle One Per Line) Totals <br /> 14 S14PH BOX Bio/Path/Pharm/Chemo Total RMW Containers: <br /> ;22 S22PH BOX Bio/Path I Pharm/Chemo <br /> 32 S32PH 28 GAL Bio/Path/Pharm/Chemo <br /> 14A+ S22PHA+ 28 GAL Bio/Path/Pharm/Chemo Estimated Gross Wt <br /> 122A+ S32PHA+ 31 GALOY Path/Pharm/Chemo (at pickup): <br /> 32A+ S64PHA+ 43 GAL Bio Path/Pharm/Chemo <br /> ;fi4A+ C22 43 GAL to/Path/Pharm/Chemo — ----• <br /> 464 C64 96 GAL Bio/Path/Pharm/Chemo RMW Actual Net Wt: <br /> 96 GAL Bio/Path/Pharm/Chemo 3 3 <br /> 200 GAL Bio/Path/Pharm/Chemo <br /> otal Sharpsmart Containers: Bale/Bag Surgical Blue Wrap — <br /> stimated Gross Wt(At Pickup): Bio/Path lPharm/Chemo <br /> harpsmart Actual Net Wt: <br /> Iransporter ID's Returned: (LG) (MED) (SM) <br /> :lean Products Delivered: <br /> 'roduct: Ordered: Otv Delivered: Notes Comments or Discrepancies: <br /> 4inimum Pick Up/Stop Charge 1.00 <br /> 3 GAL 1.00 <br /> t <br /> I <br /> Bulk Pharmaceutical,Trace Chemo,and/or Pathological waste <br /> consolidated on transfer Manifest# <br /> Date: Load q <br /> ienerator Certification: I hereby declare that the content of this consignment are fully and accurately described above by proper shipping name and are <br /> classified,packed,marked,and labeled,and are in all aspects in proper condition for transport according to applicable government <br /> reulatiodhns. <br /> I further Ia.that this shipment of waste is free of hazardous and mercury waste as defined by the US code of federal regulalior s <br /> nd/or a propri stale rubs and regulations. <br /> ienerator(Customer): t <br /> touts Driver: <br /> Na of authorized person(print): 31 nate DateQ / <br /> 2.- <br /> f Applicable) Name of authorized person(print) Signature Date <br /> ransfer Driver: <br /> Nam rized person(print) Signature Date <br /> Certiffeationafracelpt of waste asd by this manifest number. <br /> 1ficate of Receipt: `® <br /> `' Name of authorized person(print) Signature Date <br /> Cenif; tion receipt and destruction of waste as covered by this manifest number. <br /> :ertificate of Destruction: S S (,/k Q)c,� \ .e V <br /> Name of authorized person(print) Signature Date <br /> Vhite Can Gold <br /> ertificate of Destruction-Return to Customer Daniels Desttination Facility Customer <br />