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Barnett Medical Services, Inc 510-429-9911 Ph Date: 0709/2013 <br /> 30620 San Antonio St 510-429-9914 Fax Manifest 3192 ma 4� <br /> Hayward Ca 94544 Customer# 2232 <br /> EPA#CAL000331285 <br /> aerator: <br /> Transporter ID#4891 Contact: Sally Solanki Wofk:(609)466.21526 <br /> Stockton Hematolow-Onocolow weekly <br /> 2020 N California St.Ste#3 Frequency of Service <br /> Stockton,CA 95204 Pricing $950 a mo. <br /> o Transfer Facility: X Destination Facility: n Alternate Transfer Facility o Destination Facility a Alternate Destination Facility <br /> Barnett Medical Services,inc Barnett Medical Services,inc Heatthwise Services Photo Waste Recycling Inc Healthcare Environmental <br /> 30620 San Antonio St 2365 Arch Rd#200 4800 E.Lincoln Ave 2980 Kerner Blvd#C 1420 40th St NW <br /> Hayward CA 94544 Stockton CA 95215 Fowler CA 93625 San Rafael CA 94901 Fargo ND 56102 <br /> (5W)429-9911 (510)429-9911 559-834-3333 (415)459-8807' (701)282-7373 <br /> Permit#TS-87 Permit#TS/OST-106 Permit#PWR 122764 Permit#ITF-208 <br /> / <br /> Date s/6 Date-)(' 113 <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG II <br /> Sharps Containers Regulated Medical Waste PharMaceutical Trace Chemotherapu <br /> Size Qty: Size Qty: Wt Size Qty: Wt: 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 /> gal Size Qty Weight Product Delivered: <br /> v�eight: Pathogen: Item# Description, Qt: <br /> Dental Waste: <br /> Amalgam:Size Qty .Fixer:Size Qty Developer:Size City— <br /> Lead.Slze <br /> tyLead.Slze Qt Other:Size Qt <br /> Other:Type Size Qt <br /> Notes: <br /> Generator Certification: I hereby certify that the contents of this con signm ant are fu Ily and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are In all aspects in propercondltion for transport according to <br /> applicable government regulations. <br /> I furtherdeclare that this shipmentof waste is free of hazardousand mercurywaste as defined by the US codeof federal <br /> regulations and/or appropriate state rules and regulatio s, <br /> Generator(Customer) 'm <br /> Name of authorized person(prnt) Signature Date <br /> Route DriverWnature <br /> --»------- <br /> Name of autho zed person(print) Date t6Certificate of Destruction — J _— ------ <br /> Date <br /> Incineration Name of authorized person(print) to <br /> Brett Espicha 7/11/2013 <br /> Certificate of Destruction .---------------------- ------ --- <br /> Autodaved Name of authorized person(print) Signature Date <br />