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CONVERGE <br /> California Medical Waste Tracking Document (877) 773-0440 <br /> Phone:(408)436-2000 v 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.01/ <br /> .0 PERMIT# 409099 <br /> Driver Route No: SP100 Manifest Number: 13-0$.28-3C Building: Time Arrived: 6�� <br /> Time Departed:11 <br /> �, \ <br /> CNT- <br /> Waste Collected:UN3291 Regulated Medical Waste n.o.s 6.2 PGII JR LIN 3291,Regulated Medical Waste(Red bags,Sharps&Vet Waste) ❑ Pharmaceutical Waste *Check box for waste type <br /> T b# T # <br /> TuD lt� - Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# <br /> SitedJt Size Size if Size Site Size Size Size Size Size Size Size Size Size Size Size <br /> 1 'ohs i v� bs lbs t Its Ihs Ihs Ills lbs lbs lbs Ihs His lbs Ills His lbs His <br /> Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# <br /> Size Size Size Size Site Size Size Size Size Size Size Size Size Size Size Size Size <br /> lbs lbs lbsi lbs lbs b'I lbs lbs lbs lbs lb,I lbs lbs IbsI lbs lbs His <br /> Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# <br /> Site Size Size Size Size Size Size Size Size Site Size Size Size Size Size Size Size <br /> Ibs lbs lbs Its Ibs His lbs Ibs Ibs lbs lbs lbs lbs His <br /> lbs Ibs lbs <br /> TOTAL WEIG T <br /> ,.., ..- .. „, i�.,,ISS -_�ilTlltr(�EIG�T lbs x T „TgTAB:yYELGHT lhs <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 CONTAI ER/S DELIVERED SHARPS CO TAIMERIS DELIVERED PHARMA CO TAIIVERIS DELIVER'E'D <br /> .,>. . _ , ...,.� ��. ..,, .,. <br /> TYR�DeCi t? � <br /> BIO-326AL 32-GALLON RED-BAG WASTE COLLECTION CONTAINER SHARPS-5QT 5-QUARTS DISPOSABLE SHARPS CONTAINER PW-2GAL 2-GAL PHARMA CONTAINER(RED) <br /> SHARPS-1QT 1-QUAR7S DISPOSABLE SHARPS CONTAINER PW-8GAL 8 GAL PHARMA CONTAINER(RED) <br /> Signatures for Compliance and Authorizations: hlLe/ \ M <br /> ASA REPRESENTATIVE OF THE ABOVE FACILITY,I CERTIFY THAT THE CONTENT OF THIS CO GNMNET WASTE ARE FULLY AD ACCUIIETLYAS DESCRIBED ABOVE BY P PER SHIPPING NAE AND ARE SSIFIED,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 ANDIOR APPROPRIATE STATE RULES <br /> AND REGULATIONS. <br /> Customer Name <br /> Date Wednesday,August 28,2013 <br /> Generator Signature: X <br /> Please Print Full Name fer Driver Please Sign Full Name <br /> Trans <br /> Route Drive A\l _ �..--Signature X Date Wednesday,August 28,2013 <br /> Please Print Full Name please Si Name <br /> Transfer Station: Transfer Station X Date <br /> Please Print Full Name Please Sign Full Name <br /> Transfer Station Permit#TS/05T-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)834-62S2 <br />