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Daniels 'smart Inc. Tel: 559-834-6252 Manifest#: 713677 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 10232 <br /> Fresno CA 93725 Old Location# <br /> Danielci For Chemical Emergency Date: Jun 14, 2013 <br /> Spill, Leak, Fire, Exposure,or Accident Friday-606 <br /> Call CHEMTREC Day or Night <br /> 1-800-424-9300 <br /> 7 1 3 6 7 7 <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: A09-267-3913 Phone: 661-600-4368 <br /> Permit#: TSIOST-55 Permit#: NSW2239-A Permits: TS/OST-94 <br /> Waste Collected: UN 3291 Regulated Medical Waste n o.s 6.2 PG II <br /> Sharpsmart Containers Pharmaceutical Regulated Medical Waste Trace Chemotherapy <br /> Type City Net Wt. Type Qty Net Wt. Type Qty Net Wt. Type Qty Net Wt. <br /> S14 S14PH 28 GAL _ <br /> S22 S22PH _ /3�8 GAL <br /> S32 S32PH 96 GAL SubTotal <br /> S14A+ S22PHA+ <br /> Total Containers <br /> `A+ S32PHA+ SubTotal _ <br /> Estimated Gross Lbs <br /> a�2A+ �m S64PHA+ _ Pathology (at pickup): <br /> _ S64A+ – SubTotaf --- --- <br /> Total NET Lbs. <br /> SubTotal <br /> Transporter ID's Returned: (LG) —_ n ..,=�.__� __._ (MED) .�s__-.___—�� . (SM) _ <br /> Clean Products Delivered: <br /> Product: Ordered: Qty Delivered: <br /> I Notes Comments or Discrepancies: <br /> 28 GAL 7.00 <br /> I <br /> i <br /> i <br /> i <br /> Alternate Destination Facility <br /> Name: Curtis Bay Energy <br /> I Address: 3200 Hawkins Point Road <br /> City/State/Zip: Baltimore,MD 21226 <br /> Phone: (410)354-3228 <br /> Permit#: 2005-W MI-0036 <br /> aGenerator 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.is3ree of hazardous and mercury waste as defined by the US code of federal regulations and/or <br /> appropriate stateples and regulations. <br /> Generator(Customer): � .w=t a : fir, €` t'Z , <br /> Name of authorized person(print): Signature Date. <br /> Route Driver: _-� , - <br /> (If Applicable) Name of authorized person(print) Signature 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 �mm 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 />