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Date: <br /> 'en Inc 510-429-9911 Ph <br /> Barnett Medical S -0s' <br /> F11 Z& -k 510-429-9914 Fax Manifest#: <br /> 30620 San Antonio St <br /> Hayward Ca 94544 Customer# <br /> EPA#CAL000331285 <br /> Transporter ID#4891 <br /> Generator: Contact: <br /> Frequency of Service <br /> Pricing MAR 29 2013 <br /> 1p TAL HENT <br /> ,�jNVI ,;:tj <br /> c; Transfer Facility: X Destination Facility: n Alternate Transfer Facility n Destination Fac*'j q estination Facility <br /> Barnett Medical Services,inc Healthwise Services Photo Waste Recyclinvsi,jifii6 <br /> Barnett Medical Services,lnc (scare Environmental <br /> 30620 San Antonio St 2385 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 58102 <br /> (510)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 /> Date Date <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s.6.2 PG III <br /> Sharos Containers Reeulated Medical to Pharmaceutical Trace Che motheraov <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 /> 18 gal Size Qty Weight Product Delivered: <br /> Weight: Pathogen: Item# Description: Qt: <br /> Qental!Ka—ste.- <br /> Amalgam:Size Qty_Fixer:Size Qty Developer:Size Qty <br /> Lead:Size-Qt_ Other:Size_Qt�_ <br /> Other:Type —Size—Qt-- <br /> Notes: <br /> Ulip, <br /> k-- <br /> Generator Certification: I herebycertify that thecontents of this cons�nmentare fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in allaspects in properconclition for transport according to <br /> applicable government regulations. <br /> I further declare that this shipment of waste is free of hazarcloqsand mercurywaste as defined by the YS code of federal <br /> regulations and/or appropriate state rules arid regulations. <br /> -A4 <br /> Generator(Customer) <br /> Name of person(i6o Sig'ature Date <br /> Route Driver <br /> Name of authorized person(print) Signature Date <br /> Certificate of Destruction <br /> Incineration Name of authorized person(print) Signature Date <br /> Certificate of Destruction <br /> Autoclaved Name ofauthodzed person(print) Signature Date <br />