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0 0 . <br /> -429-9911 Ph Date: 04/02/2013 <br /> A <br /> W'TtBarnett Medical Services, Inc 510 Manifest M 32759 <br /> 30620 San Antonio St 510-429-9914 Fax customer# 2232 <br /> Hayward Ca 94544 <br /> EPANCAL000331285 <br /> ierator: Transporter ID#4891 Contact: Sally Solanhi Wax:C49)4666*626 <br /> Stockton Hematolo(w-Onocolow <br /> Frequency of Service <br /> 2626 N California St,Ste#3 <br /> Stockton,CA 05204 Pricing $960 a mo. <br /> a Transfek Facility: X Destination Facility: ternate Transfer Facility o Destination Facility 13 Alternate Destination Facility <br /> Barnett Medical ServIcesjnc Barnett Medical ServIces.Inc Healthwise Services Photo Waste Recycling Inc Healthcare Environmental <br /> 30620 San Antonio St 2385 Arch Rd#200 4800 E.Lincoln Ave 2980 Kerr er Blvd#C 1420 40th St NW <br /> Hayward CA 94544 Stockton CA 95215 Fowler CA 93625 San Rafael CA 94901 Fargo ND 58102 <br /> (510)429-9911 (510)429-9911 559-834-3333 (415)459 07 (701)282-7373 <br /> Permit#TS-87 Permit/#'I'StOST-1 06 Permit#�NR 122764 Permit#ITF-208 <br /> Data P Data <br /> q 13 <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG 11 <br /> Sharps Containe_Ls Regulated Medical Waste Pharmaceutical TrJe Chen nothe <br /> Size Qty: Size Qty: Wt Size Qty: Wt: "SZ Qty: Wt <br /> Up to: 3 gal <br /> 2 gal 20gal 8 gal 12 a[ <br /> 4 gal 38 gal 'r-N� 9 gal 189 al <br /> 6 gal 40 gal 12 gal 20j al -7- <br /> 8 gal 44 gal 18 gal 38 al <br /> 12 gal Weight <br /> I -ral Size Qty Weight Produ ct Delivered, <br /> weight: Pathogen: Item ft Description: Qt. <br /> Dental Waste; <br /> Amalgam-Size_Qty_Fixer:SIze_Qty_Developer:Size Qty <br /> Lead-SizeQtOther:Size_Qt <br /> other:Type- Size Qt- <br /> Notes: Hours: M-Th 8:30-12:30 11:30-5. Fri 13"1 <br /> Generator Certification: I berehycertify that thecontents of this consignment are fully and accui ately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are In allaspects in propercondition for tran sport according to <br /> applicable governmentregulations. I <br /> I furtherdedare thatthis shipmentof wa Ste Is free of h r nd mercury a d finedby the US cod eof federal <br /> re Cations and/or appropriatestate rules a ula ns. <br /> Generator(Customer) C 13 <br /> Date <br /> Name of a uthortzed.person(P�rh - Signature <br /> "'free o1h u 14 rn*rmrla <br /> U'a <br /> Signature <br /> q­c� —/3 <br /> AA <br /> Route Driver I I I Offf LA 2 <br /> — <br /> Name of authnAzed person(print) sna re Date <br /> -Certificate of Destruction tXf V-a9j6,1/ <br /> incineration Name of autliorlied person(PdnO n ur Date <br /> Brett Espicha 3/4/2013 <br /> Certificate of Destruction <br /> Autodaved Name of authorized person(print) signature i Date <br />