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CUNVERGE <br /> yr <br /> California Medical Waste Tracking Document (877) 7®,-tr440 <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: 2 9-835-4141 Ext 5432 CA E.P.A.LICENSE# CAL000358901 <br /> City: Tracy State: CA Zip: 95376 Pick-up Frequency:A KLY-WED LATE AM CA D.O.T. PERMIT# 409099 <br /> �r <br /> Driver Route No: SP100 Manifest Number: 13-0905-3A Building: Time Arrived: m Time Departed: L <br /> Waste Collected:UN3291 Regulated Medical Waste n.o.s 6.2 PGII LIN 3291,Regulated Medical Waste(Red bags,Sharps&Vet Waste) Pharmaceutical Waste *Check boxfor waste type <br /> * e PHARMACEUTICAL WASTE <br /> TybTu Tu , Tub# Tub# <br /> 50 Tub# Tub# Tub# Tub# Tub# Tu b# Tub# Tub# � Tub# Tub# Tub# <br /> Siz[GesSi'z®eQQ''��Size l��g, e Size Size She Size Sire Sire Size Size Size Size Size Sire Size <br /> z�"ibs 1's bs lbs lbs lbs lbs lbs lbs lbs lbs lbs Ibs ` <1b, Ibs His <br /> Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# TVs, Tub# Tub# Tub# <br /> Site Size Size Size Size Size Size Size Size Size Size Size Size Si Size Size Size <br /> Its Ihs Ibs lb, lbs Ibs lb, lbs <br /> lbs Ibs IbsIbs lbs a lbs Iba His <br /> Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# Tub# <br /> Size Size Size Size Size Size Size Size Size Size Size Size Size Size size Size Size <br /> lbs lbs Ibs Ibs Ibs lbsi lbs! lbs Ibs IbsIbs lbs Ihs His His Iles <br /> TOTAT-WEIGHT Ibs' TOTAL WEIGHT Ibs TOTAL WEIRHT <br /> Red-Bag,Sharps,Chemotherapy$Pharmaceutical waste must be segregated and stored in separate containers. ach waste stream must be recorded separately an this manifest. <br /> RED BAG CONTAINERS DELIVERED SHARPS CONTAINEMs DELIVERED PHARMA C®NTAINER/s DELIVERED <br /> Itern,ID ResCrfptibn'; QT1r >ltemlD: •. rJ tion `: <br /> Ileac CITY (tem1D. Description ;QTY <br /> BIO.32GAL 32-GALLON RED-BAG WASTE COLLECTION CONTAINER SHARPS-SQT 5-QUARTS DISPOSABLE SHARP CONTAINER PW-26AL 2-GAL PHARMA CONTAINER(RED) <br /> SHARPS-1 QT 1-QUARTS DISPOSABLE SHARP CONTAINER PW-BGAL 8 GAL PHARMA CONTAINER(RED) <br /> An— <br /> Signatures for Compliance an Authorizations: <br /> AS A REPRESENTATIVE OF THE ABOVE FACILITY,I CERTIFY THAT THE CONTENT OF THIS CONSIGNMNET WASTE ARE FULLY AND ACCURETLY AS DESCRIBED ABOVE BY PROPER SHIP ING 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,MERCI TRY AND UNPROTECTED NEEDLES AS DEFINED BY THE US CODE OF FEDERAL REGULATIONS AND/OR APPROPRIATE STATE RULE: <br /> AND REGULATIONS. <br /> C Customer Name <br /> Generator_ pjr signature: Date Thursday,September 05,2013 <br /> ease nnrthMulItime lease Sign Fu 1 Name <br /> Transfer Driver <br /> Route Driver: signature x L, Date Thursday,September 05,2013 <br /> Please Print Full Name <br /> Please Sign Fu N e <br /> Transfer Station: Transfer Station X Date <br /> Please Print Pull Name Please Sign Fu Name <br /> Transfer Station Permit#TS/OST-ss All Chem(Stericycle) Alternative D ignated Facility Treatment Center(Incineration) <br /> Transport Permit#4707•EPA#CAL000344393 Permit# EPA Permit# PA Permit#ITF-0203*EPA#CAL000344393 <br /> Daniels Sharpsmart,Inc. Stericycle,Inc. Waste M inagement Daniels Sharpsmart,Inc. <br /> 3668 Enterprise 21 Great Oaks Boulevard 3670 Ent rprise Ave 4144 E.Therese Ave. <br /> Hayward,CA 94545(559)834-6252 San Jose,CA 95119 (408)363-1660 Hayward,CA 945 lS (760)489-5009 Fresno,CA 93725 (559)834-6252 <br />