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r <br /> Daniels S ;mart Inc. Tel: 559-834-6252 Manifest#: 714407 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 10232 <br /> Fresno CA 93725 Old Location# <br /> Oanielq For Chemical Emergency Date: Jul 05, 2013 <br /> Spill, Leak,Fire,Exposure, or Accident Friday-606 <br /> I�IIII I�I�I VIII II'�I ILII��III III IIII <br /> Cal(CHEMTREC Day or Night <br /> 1-800-424-9300 7 1- 4 ,4 0 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: 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 II <br /> Sharpsmart Containers Pharmaceutical Regulated Medical Waste Trace Chemotherapy <br /> Type Qty Net Wt. Type Qty Net Wt. Type CIty Net Wt. Type Qty Net Wt. <br /> S14_ S14PH 28 GAL <br /> S22 _ S22PH 38 GAL <br /> S32 S32PH ,g96 GAL SubTotal <br /> ,r <br /> S14A+ S22PHA+ <br /> ffi Total Containers <br /> 'A+ S32PHA+ SubTotal " <br /> Estimated Gross Lbs <br /> os2A+ S64PHA+ Pathology <br /> (at pickup): <br /> S64A+ - SubTotal <br /> Total NET Lbs. <br /> SubTotal <br /> Transporter ID's Returned: (LG) (MED) (SM) <br /> Clean Products Delivered: <br /> Product: Ordered: Qty Delivered: <br /> 28 GAL 7.00 Notes Comments or Discrepancies: <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 as defined by the US code of federal regulations and/or <br /> appropriate state rules and regulations. <br /> Generator(Customer): <br /> Route Driver: Name of authorized person(print): Signature Date <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 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 Facilitv Transporter Customer <br />