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Barnett Medical Services, Inc 510-429-9911 Ph Date: 01'27'121'16 <br /> 112 t� 87878 <br /> 10� 3670 E Manifest#: <br /> VQ I, Enter Ave 510-266-0945 Fax <br /> LVA Hayward Ca 94545 Customer# 2232 <br /> EPA#CAL000403698 <br /> Transporter IDW91 <br /> ierator: Contact: <br /> Stockton Hematelociv Onocoln.1-1v - 'RaCW <br /> rre4bency of Service <br /> c m7a St, Ste .7 <br /> "—, <br /> 9524 Pricing <br /> c; Transfer Facility: M Destination Facility: tAwernale Transfer Facility PAlternate Destination Facility a Destination Facility <br /> Denials ShMsmaWWS Barnett Medical services,inc r Daniels Sharpsmart rtls Bay Energy Photo Waste Recycling Inc <br /> 3670 Enterprise Ave 2385 Arch Rd#200 4144 E.Therese Ave 3200 Hawkins Point Rd 2980 Kerner Blvd#C <br /> Hayward CA 94545 Stockton CA 95215 Fresno CA 93725 Baltimore MD 21226 San Rafael CA 94901 <br /> (510)429-9911 (510)429-9911 569-834-6252 (410)354-3228 (415)459.8807 <br /> Permit#TS-125 Pekm1l#TSIOST-10� Permit N TS/OST-55 Permit#2005.WMI-0036 Permit N PWR 122764 <br /> Date Dal 4uh <br /> I b <br /> Waste Collected: UN 3291 Regulated Medical Waste n.O.S.6.2 PIS 11 <br /> Shams gontalners Regulated Medical Waste Pharmpiceutical Trace Chemotherapy <br /> Size Qty: Size Qty: Wt Size Qty: Wt: Size Qty: Wt <br /> Up to: 3 gal <br /> 2 gal 20gal 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 /> .a] Size Qty Weight Product Delivered: <br /> Weight: Pathogen; Item# Description: Qt: <br /> Dental Waste: <br /> Anna I ga rn:SI ze_Qty Fixer:Size Qty_Developer:size—Qty— <br /> Leacl:Size_Qt_ Other:Size_Qt <br /> Other:Type 5 1 ze_Qt__ <br /> Notes: Ho,,,irs U.—T'i E-717-12-710. 1 1:37751 70 8:.i-OA <br /> Generator Certification: I herebycertify that the contents of this consignmentaie fully and accurately described above by proper shipping name <br /> and are classified,packed,marked,and labeled,and are in all aspects in proper cnrkditlon for transport according to <br /> applicable government regulations. <br /> I further declare that this shipment of Waste-I'A free of hazard4)and mercury waste as defined by the US code of federal <br /> la <br /> regull d Ii J1 <br /> on,and/or o7,OP late ate rules an sm 0 <br /> 4, <br /> Generator(Customer) ✓ e�'� Al2?4 <br /> Name of authorized person(print) Signature Date <br /> Route Driver <br /> Name of aut0lized person(print) Signature Date <br /> —Certificate of Destruction <br /> Incineration Name of authorized person{print) Signature Date <br /> Certificate of Destmctlonall <br /> —1 — il <br /> Autodaved Name of authorized person(print) Signature Date <br />