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L nmtBarnett Medical Services, Inc 510-429-9911 Ph Date: 0 P 113%2016 <br /> jManifest#: 6167'x`'` <br /> 3670 Enterprise Ave 510-266-0945 Fax <br /> Hayward Ca 94545 Customer# 2 2 321 <br /> EPA#CAL000403598 <br /> Transporter ID#4891 <br /> -!y sollanki 'VOTY, rKjq)4*E6-2626 <br /> ierator: Contact: <br /> Stockton Hematoloov Oinocoloov - SIIOGtency of Service <br /> .::LA.TRkTE <br /> Pricing <br /> a Transfer Fadity: M Destination Facility: P(CAlternate Transfer Facility <br /> rnate Destination Facility a Destination Facility <br /> Daniels SharparnaftBMS Barnett Medical Services,Inc Daniels Sharpsmart Y 1Surtis Bay Energy Photo Waste Recycling Inc <br /> 3670 Enterprise Ave 2395 Arch Rd JW200 4144 E.Therese Ave 3200 Hawkins Point Rd 2980 Kernor Blvd WC <br /> Hayward CA 94545 Stockton CA 95215 Fresno CA 93725 Baltimore MID 21226 San Rafael CA 94901 <br /> (510)429-9911 (510)429.9911 559-834-6252 (410)354.3228 (415)459-8807 <br /> Permit#TS-126 Permit#TSIOST-106 Permit N TS/OST-55 Permit#2005-WMI-0036 Permit#PWR 122764 <br /> Date Date l+p <br /> Waste Collected: UN 3292 Regulated Medical Waste n.o.s.6.2 PG 11 <br /> Sharps Containers Reiguiatgid Medical Waste Pharmaceutical Trace Chemotherap <br /> Size Qty: Size Qty: Wt Size Qty: Wit: Size Qty: Wit <br /> Up to: 3 gal <br /> 2 gal 20 gal 8 gal 12 gal <br /> 4 gal 38 gal -0-D 9 gal 18 gal <br /> 6gal 40 gal 12 gal 20 gal <br /> 8gal 44gal 18gal 38 gal <br /> 12 gal Weight <br /> -al Size Qty Weight Product Delivered: <br /> Weight: Pathogen: Item# Description: Qt: <br /> Dental Waste., <br /> Amalgam;Size Qty Fixer:Size_Qty Developer:Slze_Qty_ <br /> Lead.Size_Qk_ Other:Size Qt <br /> Other:Type Size—Qt <br /> Notes: Hiour-z V-Th 13:aD-12:30 I 1:0"D-5, Pri 8:30-4 <br /> Generator Certification; I hereby certify that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all aspects In proper condition for transport according to <br /> applicable government regulations. <br /> I further dedare that this shlpmentof waste Is fr eofh;a rd sand mecur wast as defined by the US code of federal <br /> epil@tlons a nd/'r app p late state rules an, lation <br /> Generator(Customer) n A,- �j I � . <br /> Name of authorized person{print) Signature Date <br /> Route Driver <br /> Name of autAorized person(print) Signature Z11/ Date <br /> -Certificate of Destruction <br /> Incineration Name of authorized person(prini) Signature Date <br /> Certificate of Destruction d"N <br /> sw'o —!L� �1� II ig <br /> Autodaved Name of authorized person(print) Signature Date <br />