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Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS6.2UN3291 <br /> Phone Number 3670 Enterprise Ave, Hayward CA 94545 <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1.Generator's ID No.: 1A. Generator's EPA No.: 1B. Generator's DEA No.: Date: 12.Tracking Form Doc.No.: <br /> W3. <br /> 9115-54260 07-24-2018 54260-07-24-2018-580609-BB <br /> Generator's Name and Site Address: 3A. Generator's Name and Billing Address: <br /> Satellite Dialysis-Stockton Satellite Healthcare <br /> 1801 E March Ln 300 Santana Row 300 <br /> Stockton,CA 95210 San Jose,CA 95128 <br /> 4.Generator's Phone Number(s)with Area Code: 4A: Generator's Billing Phone Number with Area Code: <br /> (209)473-6890 (650)404-3600 <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 /> (800)748-1803 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 /> <br /> <br /> (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:13e7e65 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:14198e6 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:143f673 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:146a6a5 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:149659c 40 gal Bio Disposal (1) 50.00 <br /> UN3291,Regulated Medical Waste, N.O.S,6.2, PG II QR:14ad519 40 gal Bio Disposal (1) 50.00 <br /> AM UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:147f7e5 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S,6.2, PG II QR:1454cb8 40 gal Bio Disposal (1) 50.00 <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 /> X X Date 07-24-2018 <br /> Signa Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X X Marty Montez Date 07-24-2018 <br /> HaulersAanik6re 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"was treated in accordance with applicable legal requirements on the date <br /> indicated <br /> K 7JU��✓ ✓` � a- <br /> 07-24-201$ X <br /> Signature Date Signature Date <br /> X BRETI' ESPICHA X <br /> Print Name Print Name <br />