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Emergency BarnettMedical Services' Inc CAL. RNIA RMW-CLASS6.2UN3291 <br /> Phone Number 0 Enterprise Ave, Hayward CA 5 <br /> ( 1 )429-9911 REGULATED MEDICAL. WASTET CKING FORM <br /> 1.Generator's ID No.: 1A.Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 43141-59527 1 1 104-19-2017 59527-04-19-2017-241613-BB <br /> 3.Generator's Name and Site Address:, 3A.Generator's Name and Billing Address: <br /> The Black Rose Tattoo Parlor The Black Rose Tattoo Parlor <br /> 237 E Miner Ave 237 E Miner Ave <br /> Stockton,CA 95202 Stockton,CA 95202-2328 <br /> 4.Generator's Phone Number(s)with Area Code: 4A:Generator's Billing Phone Number with Area Code: <br /> (209)817-3899 (209)817-3899 <br /> 6.Transporter Company Name: 7.Transporter I.D.Numbers: <br /> Barnett Medical Services, Inc CALIFORNIA USDOT# <br /> 3670 Enterprise Ave, Hayward CA 94545 EPA#CAL000403598 <br /> (510)429-9911 DTSC#6183 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Stockton Barnett Medical Services Daniels Sharpsmart <br /> 2385 Arch Airport Rd 2385 Arch Airport Rd 4144 E Therese Ave <br /> Stockton,CA 95206 Stockton,CA 95206 Fresno,CA 93725 <br /> (510) 240-1900 Permit#:TS/OST-106 Permit#:TS/OST-106 (559)834-6252 Permit#:TS/OST-55 <br /> 11. Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) <br /> UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:le048el D04/20/2017 40 gal Bio Disposal (1) 25.00 <br /> 14 Special Handling Instructions and Additional Information: <br /> Treatment System: <br /> 15)Generator's Certification: <br /> I hereby declare that the contents of this consignment are fully and accurately described above,and are classified,packaged,marked and <br /> labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national <br /> governmental regulations. <br /> Date 04-19-2017 <br /> Signature Print Name <br /> 16) Barnett Medical Services,Inc CALIFORNIA <br /> X X Marty Montez Date 04-19-2017 <br /> HaulersXia ure Print Name <br /> 17) Discrepancy Indication Space: <br /> Initials: <br /> Date: <br /> 18) Receipt of Materials Covered by this Tracking Document: 19)Certificate of Destruction: The signature below certifies that the waste documented <br /> on this"tracking"w eated in accordance with applicable legal requirements on the date <br /> indicated <br /> 7 0 -1 -2017 ► ""__ <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X BREI T ESPICHASTROYE <br /> Print Name Print Name 1 04/20/2017 <br />