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From-New Hope Post Acute Care 209 832 2273 77/10/2016 07:35 4075 P.012/014 Daniels Sharpsmart Inc. Tei: 559-834-6252 Manifest#: 773557 • 4144 E Therese Ave Fax:559-834-2242 Customer#: 1686 -11 11 Fresno, CA 93725 snip's For Chemical Emergency Date: May 03,2016 Spill,Leak, Fire,Exposure,or Accident Tuesday-610 Call CHEMTREC Day or Night ( iI 1-800-424-9300 7 7 . 3 5 5 7 Generator. T T Carrier: Transporter Permits: State ID No.: Daniels Sharpsmart, Inc. CA-4707 New Hope Post Accute Care 111 W Jackson Blvd EPA#CAL000344393 2586 Buthmann Ave Suite 720 Tracy CA 953762165 Chicago,IL 60604 US DOT# 1295076 Attn:Dolly Bindra 312-546-8900 (209)832-2273 Vehicle Decal: Destination Facility: Alternate Destination Facility Transfer Facility: paniel arps art Inc. HealthWise Services Daniels-Fresno Plant 41 E Therese Ave 4800 E Lincoln Ave 4144 East Therese S F sno,CA 93725 Fowler,CA 93625 Fresno CA 93725 Transfer Receipt Signature&Date: Phone: 9.834-6252 Phone: 559834-333 Phone. ( ) - Permit#: T ST-5 Permit lf: TS-89 Permit If: Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG Il OR Material Type Tvae Qty Net Wt. Type Net Wt. Type 2t-y Net Wt. (Circle One Per Line) Totals S14 -® S14PH _ BOX Bio/Path/Pharm/Chemo To R W Containers: S22 __ W �- S22PH BOX �._. Bio/Path/Pharm/Chemo S32 S32PH 28 GAL Bio/Path/Pharm/Chemo S14A+ _ - S22PHA+ 28 GAL B-o/Path/Pharm/Chemo Estimated Gross Wt S22A+ S32PHA+ - 31-AL �!`� Bio Path/Pharm 1 Chemo (at pickup): S32A+ _ S64PHA+ 43 GAL Bio/Path/Pharm/Chemo S64A+ . C22 43 GAL _ _ Bio/Path/Pharm/Chemo C64 �r 96 GAL Bio/Path/Pharm/Chemo RMW Actual Net Wt: 96 GAL Bio/Path/Pharm/Chemo 200 GAL _ Bio/Path/Pharm/Chemo Total Sharpsmart Containers: . ._, Bale/Bag Surgical Blue Wrap .� Estimated Groes wt Pickup): _ Bio/Path/Pharm/Chemo Sharpsmart Actual Netof Wt: t '"'"-'-" "' "--- �'-'— Transporter ID's Returned: (LG) ._.._ . . ..___ _� (MED) r__ (SM) Clean Products Delivered: Alternate Destination Facility Alternate Destination Facility Product: Ordered: Qty Delivered: Curtis Bay Energy Healthcare Environment Service, Minimum Pick Up/Stop Charge 1.00 3200 Hawkins Point Road 1420 40th Street NW Baltimore,MD 21226 Fargo,ND 58102 43 GAL 1.00 ``„® � , Phone: 443-692-2300 Phone: 701-282-7373 �” Permit If: 2005-WMI-0036 Permit ti: ITF-208 Notes Comments or Discrepancies: Bulk Pharmaceutical,Trace Chemo,and/or Pathological waste consolidated on transfer Manifest If Date: Load 0 Generator Certification: I hereby declare that the content of this consignment are fully and accurately described ove by proper shipping name and are classified,packed,marked,and labeled,and are in all aspects in propercondition for naport according to applicable government regulations further dectare that this shipment of waste is free of hazardous and mercury we as defined by the US co c4e of federal regulations and/or appropriat to a Nles reg la tions. Generator(Customer): , I _rr�pf uthq/(ze erso (pnt): Signature Date �,3 Route Driver: rYNr��I (Jy( 1'J (If Applicable) Name of authorized person(print) Signature pate Transfer Driver: Name of authorized person(print) Signature Date Certification of receipt of waste as cover y his manifest number. ,,..,tificate of Receipt: Certification of receipt and destruction of waste:,Asecovered by this merrilfe�t number.