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ZBarnett Medical Services, Inc 510-429-9911 Ph Date: 112A.9`2016 <br /> N44 3670 Enterprise Ave 510-266-0945 Fax Manifest#: 8-8-54-5 <br /> Hayward Ca 94545 Customer# 2232 <br /> EPA#CAL000403598 <br /> ierator: Transporter 1D#4891 Contact: ',;ally solanid 'v-`IrK�W9)4EE-262F <br /> Stockton Hetnatolotiv Onocolow - StDck! veek:y <br /> 2626 19 C a!jfi,,rrf3 St.Ste*3 Frequency of Service <br /> PLAT RATE <br /> f <br /> St '�ti%r-•'�A 1,52,)4 Pricing <br /> a Transfer Facility. 11111 Destination Facility- lennale Transfer Facility /AJItemata Destination Facility o Destination Facility <br /> niels Sharpsmart Photo Waste Recycling Inc <br /> Daniels ShorpsmtVBMS Barnett Medical ServicasJoc &Da itis Bay 15norgy <br /> 3870 Enterprise Ave 2395 Arch Rd#200 4144 E.Therese Ave 3200 Hawidns Point Rd 2980 Kerner Blvd#C <br /> Hayward CA94545 Stockton CA 95215 Fresno CA 93725 Baltimore MD 21226 San Rafael CA 94901 <br /> (510)429-9911 (510)429-9911 559-&34-6262 (410)354-3228 (415)46943807 <br /> Permit#TS-125 Permit#TSIOST-11 06 Permit N TWOST-55 Permit#2005-WM[4)036 Permit#PWR 122764 <br /> pate L_ Date <br /> Waste Collected: LIN 3291 Regulated Medical Waste in.o.s.6.2 PG 11 <br /> Sha[Rs Containers Regulated Medical Waste Pharmaceutical Trace Chernotherap <br /> Size Qty: Size ' Qty: Wt Size Qty: Wt: Size. Qty,- Wt <br /> Up to: 3gal <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 /> Sgai 44 gal 18 gal 38 gal <br /> 12 gal Weight <br /> I -a[ Size Qty Weight Product Delivered: <br /> Weight: Pathomin: Item# Description: Qt: <br /> Dental Waste: <br /> Amalgam:Size Qty Fixer:Size Qty_Developer:Size Qty <br /> Lead:Slze_QL Other;Size M-- <br /> Other:Type Size_Qt�__ <br /> Notes: Hours NA-Th,8:30-12.3-01 Fri 8:30-4 <br /> Generator Cerdfication. I herebycertify that the contents of this consignmentare 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 declare that this shipment of wase is free of haz ou and ercuryw t deft d by the US code of federal <br /> regilatl ns and/ r 0 1 ate rules and regulad <br /> ;7,,li sates <br /> Generator(Customer) _14,111 'X I - I <br /> Name of authorized person(print) Signature Date <br /> Route Driver aik Al—'e2— t2 ) 0211611161 <br /> Name of autiforlized person 1prino Signature Date <br /> -Certificate of Destruction <br /> Incineration Name of authorized person(print) Signature Date <br /> Certificate of Destruction <br /> Autodaved Name of authorized person(print) Signature Date <br />