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Daniels Parpsmart Inc. <br /> 4144 E Therese Ave Tel: 9-834-6252 Manifest#; 752412 <br /> 66 <br /> Fresno, CA 93725 Fax:559-834-2242 Customer#: 1946 -62 <br /> ': '••s ••• :T".u: °,::fr, For Chemical Emergency Date: <br /> Spi1I,Leak,Fire,Exposure,or Accident Jun 02,2015 <br /> Call CHEMTREC Day or Night Tuesday-6)R10If i <br /> _ 1-800-424-9300 <br /> Generator: 7 5 2 4 1 2 <br /> State ID No.: Carrier: Transporter Permits. <br /> SUTTER TRACY COMMUNITY HOSPiTA Daniels Sharpsmart, Inc. CA-4707 <br /> 1420 N Tracy Blvd 111 W Jackson Blvd EPA#CAL000344393 <br /> Tracy CA Pedro Gonzales Suite 720 <br /> Attn:Heidi-EVS Manager 95376 Chicago,IL 60604 <br /> (20911832-6053 <br /> 312-546-8900 US DOT#1295076 <br /> Des ination Facility: Vehicle Decal: <br /> I ate Destinati Facility Transfer Facility: <br /> J� jDaniels Sharpsmart Inc. Ba nergy <br /> {{{ ' 4144 E Therese Ave 200 ki int Road 4144EDaniels-Fresno Plant <br /> Fresno,CA 93725 ltimor21226 FresFres o Therese <br /> e no CA 93725 <br /> Phone: $59.834.6252 Phone: 4 3- -230 Transfer Signature$Date: <br /> Permit ft: TS/OST-55 Phone: O <br /> _ Permit#: 20 036 Permit#: <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG II OR ®$� <br /> Type try Net Wt, Tvt�a Material Type <br /> S14 � Net Wt. T e Qty Net Wt• (Circler Line) Totals <br /> S14PH BOX <br /> S22 _ 322PH Bio/Path/Pharm/Chemo Total RMW Containers: <br /> S32 m S32PH BOX Bio/Path/Pharm/Chemo <br /> S14A+ 28 GAL Bio/Path/Pharm/Chemo <br /> 822PHA+ 28 GAL <br /> S22A+ �� g32PHA+ ®- Bio/Path/Pharm/Chemo Estimated Gross Wt <br /> S6aA+ <br /> S32A+ ry S64PHA+ 31 GAL Bio/Path/Pharm/Chemo (at pickup): <br /> 43 GAL <br /> C22 43 GAL Bio/Path/Pharm/Chemo <br /> - <br /> C64 96 GAL m Bio/Path/Pharm/Chemo <br /> Bio/Path/Pharm/Chemo RMW Actual Net Wt: <br /> 1 96 GAL - � � Bio/Path/Pharm/Chemo <br /> Total Sharpsmart Containers: -.;' 200 GALBio/Path/Pharm/Chemo <br /> Estimated Gross Wt(At Pickup): Bale/Bag �� W_� Surgical Blue Wrap <br /> sharps mart Actual Net Wt: Bio/Path/Pharm/Chemo <br /> Transporter ID's Returned: (LG) -_ <br /> Clean Products Delivered; "" -- _.. (MED) _ _ (SM) <br /> Pro" odu__ ct. Ordered: - <br /> Charge Per Manifest 1.00 2 Delivt:red Notes Comments or Discrepancies: <br /> Stop Fee (JN M <br /> Minimum Pick Up/Stop Charge 1.00 ja lots S32 PH 1.00 <br /> 6.00 <br /> Alternate Des nation Facility <br /> Name: Healthcare Environm ta!Service Inc. <br /> Address: 1420 40th Street NW I <br /> City/State/Zip' Fargo ND 58102 <br /> �. _ Phone: 701-282-7373 <br /> Permit#: ITF-208 <br /> Generator Certification: I hereby declare that the content of this consignment are fully and accura I describe <br /> classified,packed,marked,and labeled,and are in all as in proper coy ove b Proper <br /> ulations. y p p applicable <br /> and are <br /> >u er declare that this shi <br /> p ant of waste is tree of h ous and mercury waste as defined by�t according <br /> IUS tcodepof�tederal regulations <br /> rappropnete state ruin regulations. <br /> Generator(Customer): a <br /> Route Driver: N f u ori ed er o r t: ?ff, 0 <br /> ignat Date _ <br /> T D Name of authorized person(print) <br /> Transfer Driver: ) .`signature .� <br /> Date <br /> Name of ed person(print) <br /> Ce ifica of r 5t nu a Date <br /> 'pt of waste as Cove this manifest number. <br /> ..ficate of Receipt: <br /> Name of authorized person(print) <br /> Certiricat1 f receipt and destru tion of was as covers nature Date -� <br /> y this me 'fest number. <br /> Certificate of Destruction: _ <br /> Name of authorized person(print) <br /> White Signature <br /> Certificate of Destruction-Return to Customer Cana Gold <br /> Date <br /> ReturnDaniels Destination Facility Customer <br />