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Barnett Medical Services, Inc 510-429-9911 Ph Date: 111`0(3•2P-16 <br /> 3670 Enterprise Ave 510-266-0945 Fax P.6 7 9'A <br /> V ma Manifest M Hayward Ca 94545 Customer# 2232 <br /> EPWAL000403598 <br /> Transporter I0#4891 <br /> y <br /> nerator: Contact: all <br /> Stockton Hamayoloqv Onocolociv -SIROUency of Service <br /> 0 <br /> Swn'l.tnn'C-Al Pricing <br /> a Transfer Facility: X Destination Facility: 14 Alternate Transfer Facility Alternate Destination Facility 13 Destination Facility <br /> Daniels SharpsmarUHMS Barnett Medical Services,inc 'Daniels Sharpsiniiarl ",Curtis Bay Energy Photo Waste Recycling Inc <br /> 3670 Enterprise Ave 2385 Arch Rd#200 4144 E.Therese Ave 3200 Hawkins Point Rd 2980 Kamer Blvd#G <br /> Hayward CA 94545 Stockton CA 95215 Fresno CA 93725 Baltimore MD 21226 San Rafael CA 94901 <br /> (510)429-9911 (510)429.9911 669-834-6252 (410)354.3228 (415)459-6807 <br /> Permit H TS-125 Pa lt#TSIOST-104 Permit#TSIOST-65 Permit#2005-WMI-0036 Permit#PWR 122764 <br /> Date <br /> Waste Collected: LIN 3291 Regulated Medical Waste n.o.s.6.2 PG 11 <br /> SharpS Containers Regulated Medical Waste Pharmaceutical Trace Chemotheraav <br /> Size Qty: Size Qty: Wt Size MY: Wt: Size Qty: Wt <br /> Up to: 3 gat <br /> 2 gal 20gal 8 gal 12 gal <br /> 4gal 38 gal Ic 9 gal 18 gal <br /> 6 gat 40gal 12 gal 20 gal <br /> 8 gal 44gal 18 gal 38gal <br /> 12 gal Weight <br /> ,al Size Qty Weight Product Delivered: <br /> v,eight: Pathogen: Item# Description: Qt. <br /> Dental Waste: <br /> Ama Iga m:Size_Qty-Fixer;Sl ze_Qty_Devel oper:Size_Qty_ <br /> Lead:Size-Qt Other:Size-Qt__ <br /> Other:Type Size_Qt_ <br /> Notes- ".o -T rj-q:-3q- '4.0 11 so ,Ij, Fri S.3 n--41 <br /> Generator CertIfication: I herebycertify that the contents of this consignment are filly and accurately described above by proper stripping name <br /> and are classified,packed,marked,and labeled,and are in allaspects in proper condition for transport according to <br /> applicable government regulations. <br /> I further declare thatthis shipmentof waste" the US code of federal <br /> regufats pns and/or appropria state and <br /> Generator(Customer) Z" <br /> Name of authorized person(print) SignatureDate <br /> Route Driver I" A�a— /-&-Y( .0 <br /> Name of at4orized person(print) signature Date <br /> Of Destruction <br /> Incineration Name of authorized person(print) signature Date <br /> Certificate of Destruction hen <br /> Autodaved Name of authorized person(print) Signature Date <br />