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Barnett Medica{ Services, Inc 510-429-9911 Ph Date: 01/2212013 <br /> 1 20 ;4 30620 San Antonio St 510-429-9914 Fax Manifest#: 27942 <br /> Hayward Ca 94544 Customer# 2232 <br /> EPA'4CAL000331285 <br /> Transporter IDN 4891 <br /> Aerator: Contact: Sally Solanki Work:(M)455.2626 <br /> Stockton Hemato#ow-Onocoloqv waaw <br /> Frequency of Service <br /> 2020 N California St,Ste#3 Y <br /> Stockton,CA 95204 Pricing $950 a mo. <br /> a Transfer Facility: X Destination Facility: Remate Transfer Facility o Destination FacilityAlternate Destination Facility <br /> Barrell Medica!Services;lnc Barnett Medical Servlces,inc Daniels Sharpsmart Photo Waste Recycling Inc ealthcare Environmental <br /> 30620 San Antonio St 2385 Arch Rd#200 4144 E.Therese Ave 2980 Kerner Blvd#C 1420 40th St NW <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 TS/OST-106 Permit#TS/OST-55 Permit#PWR 122764 Permit#ITF-208 <br /> Date Date t` r�71 <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 �L! <br /> 12 gal Weight <br /> 11Pathogen: Size Qty Weight Product Delivered: <br /> Weight: Item# Description: Qt: <br /> Dental Waste: <br /> Amalgam:Size Qty Fixer:Size Qty Developer:Size CRY— <br /> Lead. <br /> tyLead.Size Qty 0ther:Size Qty <br /> Other:Type: Size Qty <br /> Nates: ours: n :30-4 <br /> Generator Certification: I hereby certify that the contents of this consgnmentare fuiy and accurately described above by proper shipping name <br /> and are ctasslfled,packed,marked,and labeled,and are in all aspects In proper condition for transport according to <br /> applicable government regulations. <br /> I further declare that this shipmentof waste Is free of usand mercury waste as defined by the US cad eof federal <br /> regi Cations and/or appropriate state ru les and regu ons. <br /> Generator(Customer) — <br /> Name of authorized person(prin Signature Date <br /> Route Driver --- ------- -"—;6)- _. <br /> Name of aut ized person(print) gna—e Dat? <br /> w C� r a Y(J 3 <br /> -Certificate of Destructione �_Incineration Name Name of authorized person(print) tur —�--—� — — Date — <br /> Brett Espicha �' 1/24/2012 <br /> Certificate of Destruction ----------- —^_------------------� <br /> Autodaved Name of authorized person(print) Signature Date <br />