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From-Nevv Hope Post Acute Care 209 832 2273 11/10/2016 07-36 4015 P.014/014 <br /> Ganielb Sharpsmart Inc. Tel: 559-834-6252 Manifest M 775243 <br /> 4144 E Therese Ave F :559-834-2242 Customer#: 1686 -11 <br /> Fresno, CA 93725 <br /> Daniels' For Chemical Emergency Date: May 31,2016 <br /> Making K"ftara Sato Spill,Leak,Fire,Exposure,or Accident Tuesday-610 <br /> Call CHEMTREC Day or Night I <br /> 1-800-424-9300 <br /> 7 7 5 2 4 3 <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 <br /> Vehicle Decal: <br /> Destinat'1py��Facility: Alternate Destination Facility Transfer Facility: <br /> `�Daniels Sharpsmart Inc. HealthWise Services Daniels-Fresno Plant <br /> 4144 E Therese Ave 4807 E Lincoln Ave 4144 Fast Therese <br /> r <br /> Fresno,CA 93725 Fowler,CA 93625 Fresno CA 93725 Transfer Receipt Signature&Date: <br /> Phone: 559-834.6252 Phone: 559834-333 Phone: ( ) <br /> Permit#: TS/OST-55 Permit#: TS-89 Permit M <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG 11 OR <br /> Material Type <br /> Type Net Wt Type Qty Net Wt. Type � 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 Bio/Path/Pharm/Chemo <br /> S14A+ S22PHA+ 28 GAL Bio/Path/Pharm/Chemo Estimated Gross wt <br /> S22A+ S32PHA+ 31 GAL BID/Path/F harm/Chemo (at pickup): <br /> S32A+ S64PHA+ 43 GAL Biq/Path/Pharm/Chemo <br /> S64A+ C22 43 GAL /path/Pharm/Chemo <br /> C64 96 GAL Bio/Path/Pha-m!Chemo RMW Actual Net Wt: <br /> 96 GALBio/Path/f�hz I m!Chemo <br /> 200 GAL Bio/Path/Pharm/Chemo _ <br /> Total Sharpsmart Containers: /Bag Surgical Blue Wrap <br /> Estimated Gross wt(At Pickup), Bale Bio!Path/Pharm/Chemo <br /> Sharpsmart Actual Net Wt: <br /> Transporter ID's Returned: (LG) (MED) ' <br /> _ (SM)__ <br /> Clean Products Delivered: Alternate Destination Facility Alternate Destination Facility <br /> Product: Ordered: Qj 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 \ n \ Phone: 443-892.2300 Phone: 701-282-7373 <br /> a_y\u�-(J� / Permit M 20D5-WMI-0036 Permit#: ITF-208 <br /> Notes Comments or Discrepancies: <br /> �J Bulk Pharmaceutical,Trace Chemo,and/or Pathological waste <br /> consolidated on transfer Manifest g <br /> Date: Load N <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 apptir ble government <br /> reg <br /> ulations. <br /> .i furtherdeclare that this shipment of waste is free of hazardous ar}d,mercury waste as defined by the U$�C� deral regulations <br /> and/or proprtate stale rules and regulations. ! / t Q✓�'//1 <br /> Generator(Customer): V �kn� j e-':� Glu <br /> Na a pf autho zed flarson(print): SI® �e Date <br /> Route Driver: ® eYZ410r <br /> (If <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 anifest number. <br /> __.;ificate of Receipt: /�y�r���� ii L �l.► 1j <br /> Certification of receipt and destruction of waste as covered by this manifest number. <br />