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Prom-New Hope Post Acute Care 209 832 2273 11/10/2016 07:34 0016 P.010/014 <br /> Daniels Sharpsmart Inc. Tel: 559-834-6252 Manifest#: 759897 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 1686 -11 <br /> antet5 Fresno, CA 93725 <br /> For Chemical Emergency Date: Sep 29,2015 <br /> 1.4tke.p Nenntrma swr4 Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night <br /> 1-800424-9300 7 5 9` 8 9 7 <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 OOT#1295076 <br /> Attn:Dolly Bindra 312-546-8900 <br /> ftele <br /> Vehicle Decal: <br /> acility. Alternate Destination Facility Transfer Facility: <br /> ls Sharpsmart Inc. Curtis Bay Energy Canals-Fresno Plant <br /> E Therese Ave 3200 Hawkins Point Road 4144 East Therese <br /> o,CA 93725 Baltimore.MD 21226 Fresno CA 93725 Transfer Receipt Signature&Date: <br /> 834-6252 Phone 443-692-2300 Phone: <br /> ST•55 Perm" #: 2005-WMI-0036 Permit#:cted: UN 3 egulated Medical Waste n.os 6.2 PG II OR -- <br /> Material Type <br /> Type (�( Net Wt. Type Qty Net Wt. Type Qtj Net Wt. (Circle One Per Line) Totals <br /> S14 __M__ S14PH _ BOX Bio/Path!Pharm/Chemo Total�W Containers: <br /> S22 r S22PH w�- BOX - Bio/Path/Pharm/Chemo <br /> S32 _ _ S32PH _ - 28 GAL _ Bio/Path/Pharm/Chemo <br /> S14A+ _ �, S22PHA+ s 28 GAL Bic/Path/Pharm/Chemo Estimated Gross Wt <br /> S22A+ __ _�— _ S32PHA+ 31 GAL _ _ _ Bio/Path/Pharm/Chemo (at pickup): <br /> S32A+ _ _ _ S64PHA+ 1 43 GAL �_ gtt/Path/Pharm/Chemo <br /> S64A+ �- C22 _ __ _ ' 43 GAL _ o/Path/Pharm/Chemo <br /> C64 96 GAL Bio/Path/Pharm/Chemo RMW Actual Net wt: <br /> ! 96 GAL _ Bio/Path/Pharm/Chemo <br /> 200 GAL Bio/Path i Pharm/Chemo <br /> Total Sharpsmart Containers: _—r 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: 4 <br /> Product Ordered: Qri Delivered: Notes Comments or Discrepancies: <br /> Minimum Pick Up/Stop Charge 1.00 <br /> 43 GAL 1.00 <br /> Bulk Pharmaceutical,Trace Chemo.and/or Pathological waste <br /> Consolidated on transfer Manifest# <br /> Data: toad# <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 of waste is free of hazardous andrcury waste as defined by the US code of federal regulations <br /> and/or appro 'a1 a sla a rules and regulations. /-j / / G/� / <br /> Generator(Customer): 1��V !LA J,-7 <br /> Na o thorize o Hnt): Signa r Date r <br /> Route Driver. ALL 8, <br /> (If Applicable) Name of authorized person(print) Slgnatu4�11 Date <br /> Transfer Driver: <br /> Name zed person(print) Signature Date <br /> Certifi ti ceipl of waste as cov red by this manifest number. (+ <br /> ificate of Receipt: _•._ V 5_S eA-& ® .Y_—r. "l— S <br /> Name of asylba4zed person(print) Signature Date <br /> Cenifrcafgn of ceipt and destruction asts as covered by this manifest number. <br /> Certificate of Destruction: — V S S ��` ^�� �S <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 />