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CONVERGE California Medical Waste Tracking Document 7 77 -0440
<br /> Phone:(408)436-2000 Fax:(408)538-3111
<br /> 1430 Koll Circle Suite 103 ❖ San Jose CA 95112 24 HRS EMERGENCY PHONE:(408)436-2000
<br /> Generator's Information: Account Number: 299199 TRANSPORTER PERMIT
<br /> Generator Deuel Vocational Institution (DVI) Contact: Lisa M.Rocha TRANSPORTER PERMIT# 5961
<br /> Street: 23500 Kasson Road Telephone: 209-835-4141 Ext 5432 CA E.P.A.LICENSE# CAL000358901
<br /> City: Tracy State: CA Zip: 95376 Pick-up Frequency: WKLY-WED LATE AM CA D. T. PERMIT# 409099
<br /> Driver Route No- SP100 Manifest Number: 13-0807-3A Building: Time Arrived: 1 Time Departed:
<br /> Waste Collected:UN3291 Regulated Medical Waste n.o.s 6.2 PGII ❑ UN 3291,Regulated Medical Waste(Red bags,Sharps&Vet Waste) ❑ Pharmaceutical Waste (� *Check box for waste type
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<br /> Red-Bag,Sharps,Chemotherapy&Pharmaceutical Waste must be segregated and stored in separate containers.Each waste stream must be recorded separately on this manifest.
<br /> RED-BAG C®MTAINER/s DELIVERED SHARPS CONMIA/ER/s DE'LIVERE'D PHARMA CONTAINER/s DELIVERED
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<br /> BIO-32GAL 32-GALLON RED-BAG WASTE COLLECTI00 CONTAINER (P SHARPS-5QT S-QUARTS DISPOSABLE SHARPS CONTAINER PW-2GAL 2-GAL PHARMA CONTAINER(RED)
<br /> SHARPS-1 QT 1-QUARTS DISPOSABLE SHARPS CONTAINER PW-8GAL 8 GAL PHARMA CONTAINER(RED)
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<br /> Signatures for Compliance an Authort�a't n
<br /> ASA REPRESENTATIVE OF THE ABOVE FACILITY,I CERTIFY THAT THE CONTENT OF THIS CONSIGNNNET WASTE ARE FULLY AND ACCURETLY AS DESCRIBED ABOVE BY PROPER SHIPPING NAME AND ARE CLASSIFIED,PACKAGED,MARKED AND LABELED,AND ARE IN ALL ASPECTS IN PROPER CONDITION FOR
<br /> TRANSPORT ACCORDING TO APPLICABLE FEDERAL AND STATE REGULATIONS.I ALSO FURTHER DELARE THAT THIS SHIPMENT OF WASTE IS FREE OF ANY HAZARDOUS,MERCURY AND UNPROTECTED NEEDLES AS DEFINED BY THE US CODE OF FEDERAL REGULATIONS AND/OR APPROPRIATE STATE RULES
<br /> AND REGULATIONS.
<br /> Customer Name
<br /> Generator Signature: X Date Wednesday,August 07,2013
<br /> Please Print F II Name Please Sign Full Name
<br /> Date Wednesday,\ Transfer Driver Au
<br /> Route Driver: �,ft-.� �' �� Signature X L-/' y+ g ust 07,2013
<br /> Please Print Full NamA,' n° Please Sign F
<br /> Transfer Station: Transfer Station X Date
<br /> Please Print Full Name Please Sign Full Name
<br /> Transfer Station Permit#TS/OST-55 All Chem(Stericycle) Alternative Designated Facility Treatment Center(Incineration)
<br /> Transport Permit#4707•EPA#CAL000344393 Permit# EPA Permit# EPA Permit#ITF-0203•EPA#CAL000344393
<br /> Daniels Sharpsmart,Inc. Stericycle,Inc. Waste Management Daniels Sharpsmart,Inc.
<br /> 3668 Enterprise 21 Great Oaks Boulevard 3670 Enterprise Ave 4144 E.Therese Ave.
<br /> Hayward,CA 94545 (559)834-6252 San Jose,CA 95119 (408)363-1660 Hayward,CA 94545 (760)489-5009 Fresno,CA 93725 (559)834-6252
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