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Barnett Medical Services, Inc 510-429-9911 Ph Date: 01102/2013 <br /> 30620 San Antonio St 510-429-9914 Fax Manifest : 27939 <br /> Hayward Ca 94544 Customer# 2232 <br /> EPA#CAL000331285 <br /> Transporter fD#4691 <br /> aerator: Contact: Sally Soianki Werk:tM)466-2626. <br /> Stockton Hematologv;-OnoDoilo(w weekly <br /> 2626 N California St,Ste#3 Frequency of Service <br /> Stockton,CA 95204 Pricing $050 a rm. <br /> ❑ Transfer Facility: X Destination Facility: ❑ Alternate Transfer Facility n Destination Facility ❑ Alternate Destination Facility <br /> Barnett Medical Services,inc Barnett Medical Services,inc Daniels Sharpsmart Photo Waste Recycling Inc Healthcare Environmental <br /> 30620 San Antonio St 2385 Arch Rd#200 4144 E.Therese Ave 2980 Kerner Blvd#C 1420 40th St NV'1 <br /> Hayward CA 94544 Stockton CA 95215 Fresno CA 93725 San Rafael CA 94901 Fargo ND 58102 <br /> (510)429-9911 (510)429-9911 559-834-6252 (415)459-8807 (701)282.7373 <br /> Permit#TS-87 Permit#TSIOST-106 Permit N TSIOST 55 Permit#PWR 122764 Permit#ITF-208 <br /> Date <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o,s.6.2 PG II <br /> Sharps Containers Regulated Mg lcal 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 <br /> 12 gal Weight <br /> it P t o e •Size Qty Weight Prod ct 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 mokyw Qt _ <br /> Notes: <br /> Generator Certification: I herebycertify that thecontents of this con sgnmentare fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in alt aspects in propercondition for transport according to <br /> applicable government regulations. <br /> furtherdedare that this shipmentof waste is free of hazardous and mercury waste as defined by the US code of federal <br /> � t rggaJtations and/or appropriate state rules and regulations. <br /> 1rI <br /> Generator(Customer) 9,:C4-W A- ` _ �11\_ft_. — ! '�" =S— <br /> ame of authorized person( int) 5r t re !— Date <br /> Route Driver _.---_.------ <br /> ame of authorized person(p )t Date <br /> e;ertificateofDestruction �— #— <br /> Incineration <br /> Nameofauthorizedperson(pdnt) Signature Date <br /> Certlficate of Destruction ,�--- <br /> Autodaved Name of authorized person(print) Signature Date <br />