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r <br /> r r}, Daniels ShItmart Inc. Tel: 559-834-6252 J Manifest M 715022 <br /> n 4144 E Therese Ave Fax:559-834-2242 Customer#: 10232 <br /> Fresno CA 93725 Old Location# <br /> ®alnielS For Chemical Emergency Date: Aug 02,2013 <br /> 413kor i Spill,Leak,Fire, Exposure,or Accident Friday-606 <br /> Call CHEMTREC Day or Night 1111111111111111111-800-424-9300 7 1 5 0 2 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 F 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 M TS10ST-55 Permit#: NSW2239-A Perms#: 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 Net Wt. Type (ClIty Net Wt. Type (Qty Net Wt. Type (�yt Net Wt. <br /> S14 IV6 / 2- 1 28 GAL <br /> S22 S22PH 38 GAL <br /> S32 S32PH 96 GAL _ _ SubTotal <br /> S14A+ S22PHA+ t <br /> Total Containers t <br /> S22A+ S32PHA+ SubTotal _ <br /> Estimated Gross Lbs <br /> S32A+ S64PHA+ Pathology (at pickup): <br /> S64A+ SubTotal / 2 Total NET Lbs, <br /> Subtotal <br /> Transporter ID's Returned: (LG) (MED) (SM) <br /> Clean Products Delivered: _ <br /> Pr duct:GAL Ordered: Qty Delivered: i Notes Comments or Discrepancies: <br /> Alternate Destination Facility <br /> Name: Curtis Bay Energy <br /> Address: 3200 Hawkins Point Road <br /> City/State/Zip: Baltimore,MD 21226 <br /> I Phone: 443-692-2300 <br /> 1 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,a a in all aspects in proper condition for transport according to applicable government regulations. <br /> I further declare that this s eht of aste is free of hazardous and mercury waste as defined by the US cod ral regu tin and/or <br /> appropriate state rules an r ulation . '7 <br /> Generator(Customer): G <br /> Name of authorized o (print): Signature-� Date <br /> Route Driver: r �,~A -^'�C �7 _ <br /> (If Applicable) th ers n rint) Si re Date ��f'� <br /> Transfer Driver: <br /> Name of authorized person(print) Signature Date <br /> Certification of receipt of wasteBred by this manifest n <br /> Certificate of Receipt: j1rA ej/--C2 4 <br /> Name of authorized person(print) Signature Date <br /> Certification of re <br /> ceipt and destruction of waste as covered by this mmaniiffes umbe <br /> ,,,Certificate of Destruction: <br /> Name of authorized person(print) Signature Date <br /> White Green Canary Pink Gold <br />