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From:Nevv Hope Post Acute Care 209 832 2273 11/10/2016 07:36 4015 P-013/014 <br /> 1 <br /> • Daniels Sharpsmart Inc. Tel: 559-834-6252 Manifest M 774764 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 1686 -11 <br /> Fresno,CA 93725 <br /> an'els For Chemical Emergency Date: May 24,2016 <br /> ng.�nuilt:zrn!::,Ire Spill, Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night ' � � �� <br /> 1-800-424-9300 7 7 4 7 6 4 <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 /> Destina ' <br /> flit Alternate Destination Facility Transfer Facility: <br /> smart Inc. HealthWise Services Daniels-Fresno Plant <br /> 5 e Ave 4800 E Lincoln Ave 4144 East Therese <br /> 3725 Fowler.CA 93625 Fresno CA 93725 Transfer Receipt Signature 8 Date: <br /> Phone Phone: 559834-333 Phone:Permi p; Permit tf: TS-89 PermitWas CUN 3291 Regulated Medical Waste n.o.s 6.2 PG 11 OR <br /> +_ Material Type <br /> Type Net Wt. Type City Net Wt, rope t Net Wt• (Circle One Per Line) Totals <br /> S14S14PH ; BOX Bio/Path/Pharm/Chemo Total RMW Containers: <br /> S22 _- -..._ S22PH BOXBio/Path/Pharm/Chemo <br /> S32 S32PH 28 GAL - Bio/Path/Pharm/Chemo <br /> S14A+ S22PHA+ - , �., i 28 GAL ` Bio/Path/Pharm I Chemo Esti ted Gross Wt <br /> S22A+ S32PHA+ 3 GAL <br /> - ioPath/Pharm/Chemo (al pickup): <br /> S32A+ S64PHA+ 43 GAL Bio/PF <br /> th/Pharm I Chemo <br /> �+ C22 43 GAL _ Bio/Path/Pharm/Chemo <br /> _... .. <br /> C64 96 GAL . <br /> •-. - ,_ - ,. Bio(Path/Pharm/Chemo RMW Actual Net Wt: <br /> P64 _ 96 GAL _~ Bio/Path/Pharm!Chemo 2 <br /> 200 GAL _ Bio/Path/Pharm/Chemo z/ _ <br /> Total Sharpsmart Containers: Bale/Bag ."- .. Surgical Blue Wrap -- _ <br /> Estimated Gross Wt(At Pickup): �— � <br /> 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 <br /> Minimum Pick Up/Stop Charge 1.00 3200 Hawkins Point Road 1420 40th Street NW <br /> 43 GAL <br /> Baltimore.MD 21226 Fargo,ND 58102 <br /> 100 Ph <br /> . \ one: 443-692.2300 Phone: 701-282-7313 <br /> Y�►(1\�N Permit 0: 2005-WMI.0036 Permit p: iTF-208 <br /> Notes Comments or Discrepancies: <br /> i <br /> Bulk Pharmaceutical,Trace Chemo.and/or Pathological waste <br /> consolidated on transfer Manifest r1 <br /> Date; Load 0 <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 eclare that this shipment of waste is free of hazar ous and mercury waste as defined by ibis US ,of f�ef41 regulations <br /> and DropraI to rules and regulations. Gf CC��//�G' <br /> Generator(Customer): ►. dT 6'r ) l �• <br /> ame flluthoriz person mt)c Si n, e Date <br /> Route Driver: ' <br /> (If Applicable) Name of authorized person(print) Signature Date <br /> Transfer Driver: <br /> Name of authorized person(print) Signature Date <br /> Cert-�t' <br /> of receipt of w ste as covered by this manifest number. <br /> Certificate of Receipt: / vQi✓Z— �/'f /w <br /> Ceriificalion of receipt and des/ruction of waste as covered by this manifest number <br />