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Barnett Medic« e s, Inc 511-429-9911 , Date: 1071110/20-12 <br /> , Antonio St Manifest#: 7 <br /> 30620S <br /> 510-429-9914 Fax <br /> Hayward Ca 94544 Customer# 2232 <br /> EPA 'CAL000331285 <br /> Transporter ID#4891 <br /> Generator: Contact: 1 : `z, ,�.:�a . ' <br /> ;,., lens.;: <br /> StocktonHematoloctv-0nocolociv <br /> Frequency of Service {e= � <br /> 2@25 N °'�.caikfi3rif9s3 ,t,-Ste <br /> Stockon,CA 95204 Pricing Q-50 2�x <br /> ❑ Transfer Facility: X Destination Facility: ltemate Transfer Facility o Destination Facility Altemate Destination Facility <br /> Barnett Medical Services,lnc Barnett Medical Services,Inc Daniels Sharpsmart Photo Waste Recycling Inc ealthcare Environmental <br /> 30620 San Antonio St 2385 Arch Rd#200 4144 E.Therese Ave 2980'Kemer Blvd#C 1420 40th St NW <br /> Hayward CA 94544 Stockton CA 95215 Fresno CA 93725 San RaJael CA 94901 Fargo ND 58102 <br /> (510)429-9911 (510)429-9911 559-834-6252 (415)45q-8807 (701)282-7373 <br /> Permit#TS-87 Permit#TS/OST 106 Permit#TS/0ST-55 Permit# WR 122764 Permit#ITF-208 <br /> Date Date�114 f}- <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG II <br /> Sharps Containers Regulated Medical Waste Pharmaceutical Trace Chemotherapy <br /> Size Qty: Size Qty: Wt Size Qty: Size Qty: Wt <br /> Up to: 3 gal <br /> 2 gal 20 gal 8 gal 12 gal <br /> 4 gal 38 gal 9 gal 18 gal <br /> 6 gal 40 gal 12 gal 20 gal <br /> 8 gal 44 gal 18 gal 38 gal cr J <br /> 12 gal Weight <br /> 18 gal Pathogen: Size Qty Weight Product Delivered: <br /> Weight: Item# Description: Qt <br /> Dental Waste:; <br /> Amalgam:Size Qty Fixer:Size Qty Developer:Size Qty <br /> Lead:Size Qty Other:Size Qty <br /> Other:Type: Size Qty <br /> Generator Certification: I herebycertify that thecontents ofthis consgnmentare fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all aspects in propercondition for transport according to <br /> applicable government regulations. <br /> Ifurther dedare that this shipment ofwaste isfreeoff ardo sand mercury wast as de fined by the UScode offederal <br /> re lations and/or appropriate state rules and e u ons. : <br /> ., / f/ /� <br /> Generator(Customer) '�' -'�s �Gte� �` ' <br /> Name of authorized person(pr' t) ure /' t Date <br /> Route Driver <br /> Name of autho zed person(print) nature Date <br /> Certificate of Destruction <br /> Incineration Name ofauthorizedperson(print) Signature Date <br /> Certificate of Destruction <br /> Autoclaved Name ofauthorized person(print) Signature Date <br />