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OS <br />-AJL,tH IS E R V I C E S <br />Medical Waste Solutions <br />,.Ro �::"I r,!• .S+. ,a :)r"S"1Y�::'Yi 4,. fY3Ed.;iC !?i �,c�;n;>�ii.� <br />Name. <br />Address: .'��. , i` (..?.. ":C' j'a� i, i"!i +:ri-•• 243" <br />City: State: CA Zip: :>ac:;..,,_ <br />Picked Up From Customer *Check Box for Waste Type <br />0 UN 3291, Regulated Waste, n.o.s., PG 11 <br />Chemotherapy Waste, Pathology Waste, and/or Pharmaceutical <br />,it:'.}l„,iHELsULATEt)alEl)ir'AiAf2.Wh57'E X��J.t <br />Container City. Wal ht <br />20 <br />20 <br />38 <br />40 <br />44 <br />46 <br />96 <br />SUBTOTAL <br />z<..RE6t�tJ7tYEA3 RAEtMC.At. WAS'rE.�2X—u`-s?. <br />Container City, <br />Wel ht <br />20 <br />2 t y <br />26 <br />Name <br />J6 <br />Signature <br />40 <br />zg <br />44 <br />4e <br />Route Driver " <br />96 <br />SUD•TorAL '-nl <br />Signatures for Compliance and Authorizations <br />I hereby declare that the content of this consignment are fully and accunlely described <br />above by proper shipping name and aro classified. packed. marked. a.!abelod. and aro in <br />all aspects in proper condition for transport according Lo applicable government regulations. <br />Transoorter Permit #'s 6070 <br />CA Transfer Station Permit # TS -89 <br />EPA # CAL000370179 <br />Site #: iTW: ,,>r--.....:.It."IN., <br />Telephone: ` <br />Route: <br />l.x&Zz xlz::V:rRJ�.r'.t,`lr t%�iifxxts .I. 71.,$ <br />Container City. Wel hl <br />SUR -TOTAL <br />I further deebro Ilial tris shipment of waste is free of <br />haiardous and mercury wastes as defined by the us <br />Code of Federal Regulations and,'orappropnale Stale <br />Rules and Regulations. <br />10" c'— 0'-c) <br />CA <br />t � <br />Container <br />of . Weight <br />20 <br />2 t y <br />26 <br />Name <br />J6 <br />Signature <br />40 <br />(Phase Parr FULL Namor <br />44 <br />4e <br />Route Driver " <br />96 <br />W340TAL <br />Total Containers: <br />Total Gross Weight: <br />Minus Tare Weight: <br />Total Net Lbs: <br />X? . <br />Container <br />City. Weight <br />Customer F <br />2 t y <br />Customer <br />Name <br />, ti. 4.'... <br />Signature <br />�.., <br />i <br />(Phase Parr FULL Namor <br />JR— Prier FULL NarMl <br />Route Driver " <br />Route Driver: <br />Signature: <br />WP .i a Prr1, FULL Name- <br />IPkase P/ Y Fin.,, Namel <br />Transfer <br />Transfer Driver <br />Driver: <br />Signature: <br />lPleaso P -k-1 FULL Namei <br />iF'Wass Pr�A FULL Ramp - <br />Certificate of Receipt: <br />Certification of receipt of waste as covered by this manifest number, <br />Signature: <br />.. ""'-'` <br />C. <br />Certificate of Destruction: Certiftcati60.0%receipt and destruction of waste as covered by this manifest number: <br />Signature <br />X? . <br />Container <br />City. Weight <br />sue -TOTAL <br />Date! � L, i ! <br />Date: I <br />Date: et I /" <br />Contact Information <br />24 HOUR EMERGENCY PHONE: <br />1 855 246 9473 <br />Vehicle Decal: <br />Delivered to Customer- Clean Containers <br />3 < <br />(1 �sti:v .lar:$.Z.: <br />Notes, Comments, or Discrepancies <br />Name:. Daniels Sharpsmart, Inc. 3', .. "` Name Healthcare Environmentat Service. Inc. Name: Curtis Bay Energy Name:: HeallhWise Services. LLC <br />Address 4414 E. Therese Ave Address: 1420 40th Street NW Address 3200 Hawkins Point Road Address:: 4800 E. Lincoln Avenue <br />Cdylslatelbp: Fresno, CA 93725 CitylState/Zip: Fargo. ND 58102 City/Stale/Zip: Baltimore. MD 21226 City/State/Zip: Fowler. CA 93625 <br />Phonw (559)834.6252 Phone: (701) 282-7373 Phone: (443)692-2300 Phone: (559) B34-3333 <br />Permit #: TS/OST- 55 1 Permit #: ITF- 208 Permit #: 2005-WMI-0036 Permit #: TS - 89 <br />