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Daniels smart Inc. Tel: 559-834-6252 It Manifest#: 713542 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 10232 <br /> Fresno CA 93725 Old Location# <br /> For Chemical Emergency Date: Jun 07, 2013 <br /> Spill, Leak,Fire, Exposure,or Accident Friday-606 <br /> Call CHEMTREC Day or Night ! f I <br /> 1-800-424-9300 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII)IIII <br /> 7 1 3 5 4 2 <br /> Generator: Carrier: Transporter Permits: <br /> State ID No.: Daniels Sharpsmart, Inc. CA-4707 <br /> Deuel Vocational Institution 111 W Jackson Blvd EPA#CAL000344393 <br /> 23500 Kasson Rd Suite 720 <br /> Tracy CA 95304 Chicago, IL 60604 US DOT#1295076 <br /> Attn: 312-546-8900 <br /> ( ) Vehicle Decal: <br /> Destination Facility: Alternate Destination Facility Transfer Facility: <br /> Daniels Sharpsmart Inc. Waste Management Medical Waste Services <br /> 4144 E Therese Ave 7505 State Highway 65 7321 Quimby St <br /> Fresno CA 93725 Anahuac TX 77514 Incineration Signature&Date: Paramount,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 Permit#: TS/OST-94 <br /> Waste Collected: UN 3291 Regulated Medical Waste n.o.s 6.2 PG li " <br /> Sharpsmart Containers Pharmaceutical Regulated Medical Waste Trace Chemotherapy <br /> Type Qty Net Wt. Type Qty Net Wt. Type Qty Net Wt. Type Q!y Net Wt. <br /> S14 S14PH 28 GAL <br /> S22 S22PH 38 GAL <br /> S32 S32PH 96 GAL SubTotal <br /> S14A+ S22PHA+ <br /> Total Containers <br /> �A+ S32PHA+ a,®m SubTotal _ <br /> Estimated Gross Lbs <br /> a,LA+ S64PHA+ Pathology (at pickup): <br /> -JS64A+ _ SubTotal _ _ <br /> -LL Total NET Lbs. <br /> SubTotal <br /> Transporter ID's Returned: (LG) (MED) <br /> Clean Products Delivered: <br /> Product: Ordered: Qty Delivered: Notes Comments or Discrepancies: <br /> 28 GAL 7.00 <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 <br /> Permit#: 2005-W MI-0036 <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 waste is free of hazardous and mercury waste gas defined by the US code of federal re ati an&or <br /> appropriate state rules,an regulattons. 01IVA <br /> Generator(Customer): f .< • - �. ° 'h ?` a .. <br /> Name of authorized person(print): Signature Date <br /> Route Driver: <br /> (If Applicable) Name of authorized person(print) Signatures Date <br /> Transfer Driver: _ <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt of waste as covered by this manifest number. <br /> tificate of Receipt: <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt and destruction 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 />