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AV <br /> Daniels Sharpsmart Inc. Tel: 559-834-6252 Manifest#: 712961 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer M. 10232 <br /> Fresno CA 93725 Old Location# <br /> Qui 1115 For Chemical Emergency Date: May 17,2013 <br /> Spill,Leak,Fire,Exposure,or Accident Friday-606 <br /> Call CHEMTREC Day or Night 111111111I1IIIIUI1111 <br /> 1-800-424-9300 1 7tli 1 A 2 91� 6II1 <br /> Generator: Carrier: Transporter Permits: <br /> State ID No.: Daniels Sharpsmart,Inc. CA-4707 <br /> Deuei Vocational Institution 111 W Jackson Blvd EPA#CAL000344393 <br /> 23500 Kasson Rd Suite 72C <br /> Tracy CA 95304 Chicago;:IL 60604 US DOT#1295076 <br /> Attn: 312-546-8900 <br /> ( ) Vehicle Decal: <br /> Destination Facility: _ Alternate Destination FacilityT Transfer Facility: <br /> Daniels Sharpsmart Inc. Waste Management Medical Waste Services <br /> 4144 E Therese Ave 7-105 State Highway 55 7321 Quimby St <br /> Fresno CA 93725 Anahuac TX 77514 incineration Signature&Date: Paramourt,CA 90723 Transfer Signature&Date: <br /> Phone- 559-834-6252 Phone: 409-267-3913 Phone: 661-600-4368 <br /> Permit#: TS/OST-55 Permit#: NSW2239-A _ Pennrt#: TS/OST-94 <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG 11~�� <br /> Sharpsmart Containers Pharmaceutical Regulated Medica)Waste Trace Chemotherapy <br /> Type Pty Net Wt. Type Qty Net Wt. Tyge 0 ty Net Wt. Type Qtv Net Wt. <br /> S14 _ _ S14PH 28 GAL <br /> S22 m S22PH r_ GAL y ^� <br /> S32 _ __ S32PH 96 GAL SubTotal <br /> Si4A+ S22PHA+ <br /> __..._... _,Y.._.. .�_. �s__ ----.------ �-.� Total Containers .�w.._ <br /> 1;22A+ _ S32PHA+ SubTotal <br /> Estimated Gross Lbs <br /> S32A+ r r� _ S64PHA+ _ Pathology (at pickup): <br /> S6_-4+ ----- --- - -sut>Tata -- –- --— -- -------- _ <br /> Total NET Lbs. _ <br /> SubTotal <br /> Transporter ID's Returned: (LG) .� �. (MED) (SM) <br /> Clean Products Delivered: <br /> Product: Ordered: Qtv Delivered: Notes Comments or Discrepancies: <br /> 28 GAL 7.00 <br /> ! <br /> i <br /> I <br /> Alternate Destination Facility <br /> Name: Curtis Bay Energy <br /> Address: 3200 Hawkins Point Road <br /> City/State/Zip: Baltimore,MD 21226 <br /> Phone: (410)354-3228 I <br /> Permit#: 2005-WMI-0036 i <br /> Generator Certification: I hereby declare that the content of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> packed,marked,and labeled,and are in all aspects in proper condition for transport according to applicable government regulations. <br /> I further declare that this shipment of wast s fr a of hazardous and mercury waste as defined by the US code of federal re ulations and/or <br /> at�ptiate�t�telui-es and regale' _ _ — <br /> Generator(Customer): _ _ _ <br /> //;z- <br /> Name of authoriz p on(print: _ _ Si natur Date <br /> Route Driver: jyl <br /> Applicable) 0 3uth ri!kd �e o { riot -� _ na Date <br /> T <br /> Transfer Driver: (( <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt of waste as red by this manifest number <br /> Certificate of Receipt: �- ` <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt and de ruction of waste as covered by this manifest number. <br /> Certificate of Destruction: <br /> Name of authorized person(print) Signature Date <br /> White Green Canary Pink Gold <br /> Certificate of Destruction-Return to Customer Daniels Destination Facility Transporter Customer <br />