Laserfiche WebLink
From-New Hope Post Acute Care 209 832 2273 77/70/2016 07:35 4015 P_0111014 <br /> 0 go <br /> • Daniels Sharpsmart Inc. Tel: 559.834-6252 Manifest773928 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 1686 -11 <br /> Fresno, CA 93725 <br /> a �et 'rJ' For Chemical Emergency Date: May 10,2016 <br /> -i�rng veanhrarn Sarr-r Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night gl1111111111111111-800-424-9300 7 7 1113 9 2 8 <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)832-2 Vehicle Decal: <br /> DUFcility: Alternate Destination Facility Transfer Facility: <br /> ls Sharosmart c. HeatthWise Services Daniels-Fresno Plant <br /> E Therese Av 4800 E Lincoln Ave 4144 East Therese <br /> o.CA 93725 Fowler,CA 93625 Fresno CA 93725 Transfer Receipt Signature&Dale: <br /> Ph34-6252 Phone: 559834-333 Phone:PeT-55 Permit#: TS-89 PermitWct UN 3291 Regulated Medical Waste n.o.s 6.2 PG II OR <br /> Material Type <br /> Type CIty Net Wt. Type Qty Net Wt. Type Qty Net Wt. (Circle One Per Line) 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 i Bio/Path/Pharm/Chemo <br /> S14A+ S22PHA+ 28 GAL _ Path/Pharm/Chemo Estimated Gross Wt <br /> S22A+ S32PHA+ - _ 4GAL cw___ "Path/Pharm/Chemo (at pickup): <br /> S32A+ S64PHA+ , 43 GAL iPo/Path/Pharm/Chemo <br /> 4A+ _., C22 43 GAL Bio/Path I Pharm/Chemo <br /> _4 _ C64 96 GAL Bio/Path/Pharm I Chemo RMw Actual Net wt: <br /> P64 ! 96 GAL _ Bio/Path/Pharm if Chemo <br /> 200 GAL -T_Y Bio/Path/Pharm/Chemo <br /> Estimaatedced Gross C <br /> Total ss Containers: _ _ Bale/Bag _._ Surgical Blue Wrap <br /> Wt(At Pickup): _ Bio/Path/Pharm/Chemo <br /> Sharpsmart Actual Net Wt: <br /> Transporter ID's Returned: (LG) __ . __. .. (MED) _ _ (SM) <br /> Clean Products Delivered: Alternate Destination Facility Alternate Destination Facility <br /> Product: Ordered: Qty Delivered: Curtis Bay Energy Healthcare Environment Service i <br /> Minimum Pick Up/Stop Charge 1.00 3200 Hawkins Point Road 1420 40th Street NW <br /> Baltimore,MD 21226 Fargo,ND 58102 <br /> 43 GAL 1.00 \ Phone: 443-692-2300 Phone: 701-282-7373 <br /> / ® Permit#: 2005-WMI.0036 Permit#: ITF-208 <br /> Notes Comments or Discrepancies: <br /> Bulk Pharmaceutical,Trace Chemo,and/or Pathological waste <br /> consolidated on transfer Manifest# <br /> Date: Load# <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 /> 1 further declare that this shipment of waste is free of hazardous and mercury waste as define b lh US code of federal regulations <br /> r t les nd regulations. <br /> Generator(Customer): and/orappropi alb s/l�gpr_ <br /> 'Name o t 'zed Pers ( ring Sin re _ Dat <br /> Route Driver: D �/ <br /> (If Applicable) Name of authorized person(print) Signature Date <br /> Transfer Driver: <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt of waste as covered by this manifest number. <br /> Certificate of Receipt: <br /> Certification of receipt and deslniction of waste as covered by this manifest number. <br /> ae s ( ®"cb <br />