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From-Now Hopa Post Acute Care 209 832 2273 11/10/2016 07*34 0015 P.009/014 <br /> Daniels Sharpsmart Inc. Tel: 559-834-6252 Manifest#: 759460 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer M 1686 -11 <br /> Fresno, CA 93725 <br /> aniels For Chemical Emergency Date: Sep 22,2015 <br /> lAnking-6mMte--ars snrw Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night IIfII111I1I(I1i, 111 <br /> 1-800-424-9300 17 5 91 4 6 0 <br /> aerator: Carrier: Transporter Permits: <br /> atate 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 1t1 312-546-8900 <br /> (209)8 -2 3 Vehicle Decal: <br /> Destl atl�44 <br /> acility: Alternate Destination Facility Transfer Facility: <br /> iels Sharpsmart c. Curtis Bay Energy Daniels-Fresno Plant <br /> 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 /> Phon : 559-634-6252 hone: 443-692.2300 Phone: ( ) (/' SEP 2 2 2015 <br /> Permit TS/OST-55 Permit 1f: 2005-WMI-0036 _ Permit A: �XJ <br /> e q <br /> Waste lected: 3291 Regulated Medical Waste n,o.s 6.2 PG It OR ��VM <br /> Material Type <br /> Type Qty Net Wt, Type Qty Net Wt. I Type Qty Net Wt. (Circle One Per Line) Totals <br /> S14 _ S14PH ; BOX _-__ Bio/Path/Pharm/Chemo Total RMW Containers: <br /> S22S22PH _ BOX Bio/Path/Pharm/Chemo �— <br /> S32 S32PH _ 28 GAL _ Y _ Bio/Path/Pharm/Chemo <br /> S14A+ S22PHA+ 28 GAL �– u Bio/Path/Pharm/Chemo Estimated Gross Wt <br /> S22A+ S32PHA+ �� 31 GAL _ ,_ Bio I Path/Pharm/Chemo (at pickup): <br /> S32A+ S64PHA+ 43 GAL �_ ii /Path I Pharm/Chemo <br /> S64A+ C22 43 GAL _ Bio/Path/Pharm/Chemo <br /> M64 -_ C64 96 GAL ,_..... Bio/Path/Pharm/Chemo RMW Actual Net Wt: <br /> P64 96 GAL Bio/Path/Pharm/Chemo 10, <br /> Sharpsmart Containers: l 200 GAL _ �^ _ Bio/Path/Pharm/Chemo _ <br /> Bale/Bag Surgical Blue Wrap <br /> fated Gross Wt(At Pickup): <br /> Bio/Path/Pharm/Chemo <br /> Sharpsman 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 <br /> 43 GAL 1.00 i I <br /> Bulk Pharmaceutical,Trace Chemo,andlor Pathological waste <br /> consolidated on transfer Manifest# <br /> Date: Load d <br /> Generator 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 /> regulations. <br /> I further declare that this shipment ofwaste is free of hazardous and mercury waste as defined by the S code of federal regulations <br /> (Customer): <br /> dlor 11, nate 4 rules and regulations. t t; <br /> Generator Customer: •11tL� <br /> a <br /> Route Driver: M- A (print): ature(if Applicable) amorized person(print) lure D to <br /> Transfer Driver: _ <br /> Name of authorized person(print) W' Signature Date <br /> Certification of receipt of waste as covered by this manifest number. SEP 2 2 2015 <br /> Certificate of Receipt: t G <br /> Nam �ii:ed Td.struction <br /> print �. Signature Date <br /> Cert icalidn of receipt of waste as covered by this manifest number. <br /> Certificate of Destruction: W 1 ®!l^ ._ SEP 2 2 2015 <br /> Name of authorized person(print) Signature Date <br /> White Canary Pink Gold <br /> Certificate of Destruction-Return to Customer Daniels Destination Facility Customer <br />