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Prom:Now Hope Post Acute Care 209 832 2273 11/10/2016 07:33 #016 P.008/014 <br /> Daniels Sharpsmart Inc. Tel: 559-8346252 Manifest M 758977 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 1686 -11 <br /> Fresno,CA 93725 <br /> ani is For Chemical Emergency Date: Sep 15,2015 <br /> Mn41t o 04ma4hema Sul"' Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night 11111111111111111 7 <br /> 1-800-424-9300 7 5 8 9 <br /> Generator: Carrier: Transporter Permits: <br /> State ID No.: Daniels Sharpsmart,Inc. CA-4707 <br /> New Hope Post Accute Care 111 W Jackson Blvd EPA#CAL000344393 <br /> 2586 Buthmann Ave Suite 720 <br /> Tracy CA 953762165 Chicago,IL 60604 US DOT# 1295076 <br /> Attn:Dolly Bindra 312-546-8900 <br /> (209)832-2273 Vehicle Decal: <br /> Destination Facility: Alternate Destination Facility Transfer Facility: <br /> Daniels Sharpsmart Inc. Curtis Bay Energy Daniels-Fresno Plant <br /> 4144 E Therese Ave 3200 Hawkins Point Road 4144 East Therese <br /> Fresno.CA 93725 Baltimore,MD 21226 Fresno CA 93725 Transfer Receipt Signature&Date: <br /> Phone: 559-834-6252 Phone; 443-692-2300 Phone: ( ) <br /> Permit M TS/OST-55 Permit#: 2005-WMI.0036 Permit N: <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG II OR <br /> Material Type <br /> Tvpe Cyt Net Wt. Type Qty Net Wt. Type %y Net Wt. (Circle One Per 41ne) Totals <br /> S14 _ S14PH BOX Bio/Path/Pharm/Chemo Total RMW Containers: <br /> S22 S22PH BOX _ Bio/Path/Pharm/Chemo <br /> S32 __, S32PH 28 GAL Bio/Path/Pharm/Chemo <br /> S14A+ S22PHA+ 28 GAL Bio/Path/Pharm/Chemo Estimated Gross Wt <br /> S22A+ S32PHA+ 31 GAL Bio/Path/Pharm/Chemo (at pickup): <br /> S32A+ _ _ S64PHA+ 43 GAL Bio/Path/Pharm/Chemo <br /> S64A+ C22 43 GAL ®_ Bio/Path/Pharm/Chemo <br /> MR4 C64 _ - 96 GAL Bio/Path/Pharm/Chemo RMW Actual Net Wt: <br /> 96 GAL Bio/Path/Pharm/Chemo <br /> 200 GAL Bio/Path/Pharm/Chemo <br /> Total Sharpsmart Containers: Bale/Bag �� Surgical Blue Wrap <br /> Estimated Gross Wt(At Pickup): _ Bio/Path/Pharm/Chemo <br /> Sharpsmart Actual Net Wt: -- <br /> Transporter ID's Returned: (LG) (MED) . (SM) <br /> Clean Products Delivered: <br /> Product: Ordered: Qty Delivered: Notes Comments or Discrepancies: <br /> Minimum Pick Up/Stop Charge 1,00 11 <br /> 43 GAL 1.00 <br /> Bulk Pharmaceutical,Trace Chemo,and/or Pathological waste <br /> consolidated on transfer Manifest p <br /> Date: Load# _ <br /> Generator Certification: 1 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 /> regulations. <br /> I further declare that this shipment of waste is free of hazardous and mercury waste as defined by the US code o:federal regu ions <br /> a /or appropriate slate rules and regulations. <br /> Generator(Customer): M r-�L ATk <br /> a t zed a Hnt): Signetur p <br /> Route Driver: <br /> (if Applicable) Name o su horized person(print) Signature Date <br /> Transfer Driver: <br /> 4 <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt of waste as covered by this manifest number. <br /> ficate of Receipt: <br /> -' Name of authorized person(print) Signature Date <br /> Certification of receipt and destruction of waste as covered by this manifest number. <br /> Certificate of Destruction: <br /> Name of authorized person(print) Signature Date <br /> WhiteCanary Pink Gold <br /> Certificate of Destruction-Return to Customer Daniels Destination Facility Customer <br />