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8 8 <br /> Barnett Medical Services, Inc '51U-429-9911 Ph Date: U 8!21711 11 <br /> 3670 Enterprise Ave 510-266-0945 Fax Manifest M 011313 <br /> Hayward Ca 94545 Customer# .Z32 <br /> EPA#CAL000403598 <br /> Transportor lD#4B91 <br /> erator: Contact: <br /> Atoll Healz <br /> -itolociv C11101C.010CIV - stoc-k' <br /> Frequency of Service <br /> rE <br /> Pricing <br /> a Transfer Facility: 3 Destination Fadlity: #Alternate Transfer Facility Alternate Destination Facility cl Destination Facility <br /> Daniels SharpsmartIBMS Barnett Medical Services1ni; <br /> . Daniels Sharpsmart F"Curts;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#C <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 /> Pemnll#TS-1126 Permit#TS10ST-1 06 Permit#TSIOST-55 Permlt#2005-WMI-0036 Permit#PWR 122764 <br /> —Date— Dale <br /> Waste Collected: LIN 3291 Regulated Medical Waste n.o.s.6.2 PG 11 <br /> Sharps Containers —Regulated Medical Waste Pharmaceutical Trace Chemotheran <br /> Size Qty: Size Qty: wt Size Qty: Wit: Size Qty; Wt <br /> Up to: 3 gal <br /> 2 gal 20 gal 8 gal 12 gal <br /> 4 gal 38 gal L 9 gal 18 gal <br /> 6 gal 40 gal 12 gal 20 gal <br /> 8 gal 44gal 18 gal 38 gal <br /> 2 2 - <br /> 12 gal Weight <br /> 31 Size Qty Weight Product Delivered: <br /> Weight: Pathogen, Item# Description: Qt: <br /> Dental Waste: <br /> Amalgam:Size_Qty Fixer:Size. Qty_Developer:Size_Qty_ <br /> Lead:Size—Qt Other:Size Qt <br /> Other:Type Size Qt <br /> Notes: -i ours M-7)--, 30-12)-K I I-K,-t, Fri 830-4 <br /> Generator Certification: I hereby certify that the contents of this consignmentare fully and accurately described above by proper shipping name <br /> and are classifed,packed,marked,and labefed,and are in all aspects In proper condition for transport according to <br /> applicable government regulations. <br /> I further declare that this shipment of waste is free of hazpTus and mercury waste as d fin dby the US code of federal <br /> regpla ons an and/or appropr ate state rule,and r lado <br /> /;Z -A0 <br /> Generator(Customer) <br /> Name of authorized person(print) Signature Date <br /> (5 <br /> Route Driver Aul `/g <br /> Z) <br /> Name of authod/ed person(print) Signature Date <br /> Certificate of Destruction <br /> Incineration Name of authorized person(print) Signature Date <br /> Certificate of Destruction ,L,�% � <br /> a k19A <br /> Autoclaved Name of authorized person(print) Signature Date <br />