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0 <br /> DomBarnett Medical Services, Inc 510-429-9911 Ph Date: 04/30/2013 <br /> 30620 San Antonio St5iO-429-9914 Fax Manifest M 32763 <br /> Hayward Ca 94544 <br /> Customer# 2232 <br /> EPANCAL000331285 <br /> Transporter ID#4891 <br /> aerator: <br /> Contact: Sally Solanki Wo*:(209)465-2621; <br /> Stockton Hematolloclly-onocolociv <br /> Frequency of Service weekly! <br /> 2626 N California St.Ste#3 <br /> Stockton,CA 95204 <br /> Pricing $050 a Mo. <br /> 0 Transfer Facility: X Destination Facility: <br /> Barnett Medical Services.1no Barnett Medical SerVices,ine Alternate Transfer Facility a Deafinalim Facility a Alternate Destination Facility <br /> 30620 San Antonio St Healthwise Services Photo We 3to Recycling Inc Healthcare Environmental <br /> 2385 Arch Rd#200 4800 E.Lincoln Ave 2980 Karr er Blvd WC 1420 401h St NW <br /> Hayward CA 94544 Stockton CA 95215 Fowler CA 93625 San Rafao it CA 94901 Fargo ND'58102 <br /> (510)429-9911 (510)429-9911 559-834-3333 (415)459-8807 <br /> Permit#TS-87 Permit#TSIOST-1016 1(701)282-7373 <br /> Permit#9WR 122764 Permit#ITF-208 <br /> Date li Data <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG 11 <br /> Spar Cont (hers Regulated Medl it Waste Pharmaceutical Trade Chg=herm <br /> Size Qty: Size Qty: Wt Size Qty: Wt: Sizei Qty: Wt <br /> Up to: <br /> 3 gal <br /> 2 gal 20 gal 8 gal 12 g6i <br /> 4 gal 38 gal 18 9 gal I <br /> gol <br /> 6 gal 40 gal 12gal 20g�l <br /> Sgal 44 gal 18 gal 38g I <br /> 12 gal Weight <br /> ;al Size Qty Weight Prored: <br /> weight: Pat en: item# Description: <br /> Qt: <br /> Dental Waste: <br /> Amalgam:Size <br /> _Qty_Fixer:Size_Qty Developer:Size_Qty_ <br /> Lead:Size <br /> _QtL_ Other.SizeQt <br /> Other:Type Size Qt <br /> Notes: Hours: MI-Th 8:30-12:30 11:30-6. Fri 9:3D-4 <br /> Generator Certification: I herebycertify that thecontents of this consignment are fu V and I. elVdsciibed above by proper shipping name <br /> ed,packed,marked,and labeled,and are In 1.111 aspects In p olV r <br /> and are classified, per condition for transport according to <br /> applicable government regulations. I loe <br /> I furtherdeclare that this shipment of waste is fr of h arclou and mer ry rite as defined by the US code of federal <br /> regulations and/or appropriate state rulegulati S. <br /> Generator(Customer) <br /> Name of authorized person Y(4pt�) l tufa Date ———— <br /> 3 <br /> Route Driver M 3®s ® <br /> Name of authorize erson(prfnt) Date <br /> certificate of Destruction <br /> c)7 <br /> Incineration Name of authorized person(pdnt) n nx I <br /> Brett Espicha I 5/1/2013 <br /> Certificate of Destmcdon <br /> Autoclaved Name of authorizedperson(print) Signature <br /> Date <br />