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14}=iE :rti`�131t1:A4EU ' SA°A5%�....`.k.,�ix <br />Container Ot . Weight <br />20 <br />28 <br />38 <br />40 <br />44 <br />46 <br />96 <br />aVe•TbTAe <br />Transoorter Permit Ws 6070 <br />CAP+ w <br />Signatures for Compliance and Authorizations <br />I hamby tlaUara that the content of this mnsignment are (u8y arltl aeeumtaly tlesvlbed t further tlectafo thal this shipment of nate is Tree of <br />F <br />/ .. <br />CA Transfer Station Permit # TS-89H-E-ALTHWISE <br />EPA' CAL000370179go <br />S E R V I C E S <br />1 at54 <br />Minus Tare Weight: <br />Medical Waste Solutions <br />PRR 44411! <br />Customer information <br />Customer ` Customer ; <br />Contact Information <br />Name: .,i: ;.: Signature:'....- Date: <br />Print FULL N;;".., Ant FULLN— <br />:. , f / , <br />24 HOUR EMERGENCY PHONE: <br />oda Z' •nY,^ °F fL A f" -r^ ` i- ,.S" t.,Z.:....:C :F,4�-. •a(,�\" r r, <br />Name: vfP l i l�.l"a.>:" _. sc} 3L a� t . : a: s ; .... a <br />k,: <br />000302 "0.3T.�� <br />Site #: <br />Route Driver. Signature: Date: <br />1 855 246 9473 <br />Address: 53137 t.tT-F fA:v'E= ',,M1')',3 26.13 l <br />Telephone: <br />City: i? ; i_ ;_ _"?= State: ('t=: Zip: 9"136t2 <br />Route: klAj {' <br />Vehicle Decal: <br />Picked Up From Customer '"Check Box for Waste Type <br />Certificate of RecefpC ; Certification of receipt of waste as covered by this manifest number. <br />Delivered to Customer- Clean Containers <br />® UN 3291, Regulated Waste, n.o.s., PG it <br />Certificate of" Destruction: Certification of receipt and destruction of waste as covered by this manifest number: <br />Chemotherapy Waste, Pathology Waste, and/or Pharmaceutfcai <br />t <br />��'w: ra> aiJ4 ttkr a (✓ "'�5. '��. ., :��iJ F t....t^.at <br />Signature %' Date: <br />I I <br />DesignateDesignatea Facility <br />14}=iE :rti`�131t1:A4EU ' SA°A5%�....`.k.,�ix <br />Container Ot . Weight <br />20 <br />28 <br />38 <br />40 <br />44 <br />46 <br />96 <br />aVe•TbTAe <br />,r <br />3 k� <br />Container ._.__ aly. Weight <br />y SUe•TOrAL <br />Container Ot . Weight <br />20 <br />28 <br />so <br />40 <br />44 <br />48 <br />98 <br />SUR -TOTAL <br />Container Qty. Weight <br />SUB -TOTAL <br />�'it4.v a r <br />Container <br />of . Wet ht <br />Signatures for Compliance and Authorizations <br />I hamby tlaUara that the content of this mnsignment are (u8y arltl aeeumtaly tlesvlbed t further tlectafo thal this shipment of nate is Tree of <br />F <br />/ .. <br />by proper shipphlg name and are classified. packed, marked, antl labeled, and era in hazardaus and mercury wastes as defused by the US Total Containers' <br />ali aspects in proper conditim for tmnspart according to oppkmblo government fegulalidns. Code of Federal Regulations and/or apprapr010 Stale <br />Rules and Regulaliam Total Gross Weight: <br />Minus Tare Weight: <br />SUB -TOTAL <br />,r <br />3 k� <br />Container ._.__ aly. Weight <br />y SUe•TOrAL <br />Container Ot . Weight <br />20 <br />28 <br />so <br />40 <br />44 <br />48 <br />98 <br />SUR -TOTAL <br />Container Qty. Weight <br />SUB -TOTAL <br />�'it4.v a r <br />Signatures for Compliance and Authorizations <br />I hamby tlaUara that the content of this mnsignment are (u8y arltl aeeumtaly tlesvlbed t further tlectafo thal this shipment of nate is Tree of <br />F <br />/ .. <br />by proper shipphlg name and are classified. packed, marked, antl labeled, and era in hazardaus and mercury wastes as defused by the US Total Containers' <br />ali aspects in proper conditim for tmnspart according to oppkmblo government fegulalidns. Code of Federal Regulations and/or apprapr010 Stale <br />Rules and Regulaliam Total Gross Weight: <br />Minus Tare Weight: <br />Total Net Lbs: <br />Customer ` Customer ; <br />Name: .,i: ;.: Signature:'....- Date: <br />Print FULL N;;".., Ant FULLN— <br />:. , f / , <br />a x—, IPA^ssc <br />Roule Driver <br />Route Driver. Signature: Date: <br />! / <br />Notes, Comments, or Discrepancies <br />cpx— P-1 FULL N-1 IPw. Prnl FULL N-1 <br />Transfer Transfer Driver <br />Driver: Signature: Date: <br />I / <br />ip*— F,.1 FULL N—' 0... Pim FULL N. -I <br />Certificate of RecefpC ; Certification of receipt of waste as covered by this manifest number. <br />Signature ,%.,... ;w--' Fc^..,. n Date: <br />Certificate of" Destruction: Certification of receipt and destruction of waste as covered by this manifest number: <br />t <br />Signature %' Date: <br />I I <br />DesignateDesignatea Facility <br />Alternate Designated Facility <br />Designated Facility <br />Designated act rty <br />Name: Daniels Sharpsmart. Inc. <br />Name:: Healthcare Environmental Service, ine <br />Name: Curtis Bay Energy <br />Name: HealthWise Services. LLC <br />Address: 4414 E. Therese Ave <br />Address: 1420 40th Street NW <br />Address: 3200 Hawkins Point Road <br />Address: 4800 E. Lincoln Avenue <br />City/State/Zip: Fresno. CA 93725 <br />City/State/Zip: Fargo, ND 58102 <br />CilylState/Zip. Baltimore, MD 21226 <br />City/State/Zip: Fowler. CA 93625 <br />Phcne: (559) 834-6252 <br />Phone: (701) 282-7373 <br />Phone: (443) 692-2300 <br />Phone: (559) 834-3333 <br />Permit #: TS/OST- 55 <br />Permit #: ITF- 208 <br />Permit hl: 2005-W MI -0036 <br />Permit #: TS - 89 <br />