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a -? <br /> - Daniels Sh art Inc. Tel: 559-834-6252 Manifest#: 714834 <br /> 4144 E Therese Ave Fax:559-834-2242 Customer#: 10232 <br /> Fresno CA 93725 Old Location# <br /> Darnels For Chemical Emergency Date: Jul 26,2013 <br /> Spill,Leak,Fire,Exposure,or Accident Friday <br /> lI-II6''0uu6uu'' ��ww <br /> Call CHEMTREC Day or Night 1111 IIIIII1t111 1 1111 <br /> 1-800-424-9300 7 1 4 8 3 4 <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 Sharpsman 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 (Ot( Net Wt. Type pt Net Wt. Type Qt1C Net Wt. Type Qtv Net Wt. <br /> S14 S 14PH 28 GAL �. <br /> S22 S22PH 38 GAL <br /> S32 S32PH u GAL SubTotal <br /> S 14A+ S <br /> 22P.HA+ i <br /> ---�- ^--" '—'—' Total Containers <br /> S22A+ S32PHA+ SubTotal EO <br /> Estimated Gross Lbs <br /> S32A+ S64PHA+ Patholooy (at pickup): <br /> S64A+ SubTotal Y ®___ - <br /> •-�----- --- ~—"— --- Total NET Lbs. <br /> SubTotal _ <br /> Transporter ID's Returned: (LG) ___.._ (MED) (SM) <br /> Clean Products Delivered: <br /> Product: Ordered: Qty Delivered: Notes Comments or Discrepancies: <br /> 28 GAL 7.00 <br /> Alternate Destination Facility <br /> II Name: Curtis Bay Energy <br /> Address: 3200 Hawkins Point Road I <br /> City/State/Zip: Baltimore,MD 21226 <br /> Phone: 443-692-2300 <br /> Permit#: _�2005-WMI-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 ail aspects in proper condition for transport according to applicable government regulations. <br /> I further de lave that this shipment of waste is free of hazardous mercury waste as defined by the UScodeof federal regulations and/or <br /> �ppropr' t tate rules and r ui tions. <br /> Generator(Customer): - # _ <br /> Na et o ized per (pr nt):� iture Date <br /> Route Driver: -¢ <br /> (If Applicable) of abut d person(pr t) la Date -� <br /> Transfer Driver: <br /> Name of authorized person(print) Signature Date <br /> Cert�tion oft of waste as covered by is�manifest number. <br /> Certificate of Receipt: <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt and destruction of waste vered by this manifest number. <br /> l3 <br /> Certificate of Destruction: _C( -'t� .n!�.tY ----- <br /> Name of authorized person(print) Signature Date <br /> White _ _ Green Canary Pink -N Gold M^r <br />