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AS& Ah <br /> Emergency BaMtt Medical Services, Inc CALMRNIA RMW-CLASS6.2 UN3291 <br /> Phone Number P.O. Box 4436, Hayward CA 94540 <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1.Generator's ID No.: 1A.Generator's EPA N— Generator's DEA No.: Date: T2—Tracking Form Doc.No.: <br /> 39115-62763 1 0-71B. 106-14-2019 162763-06-14-2019-480217-BB <br /> 3.Generator's Name and Site Address: 3A.Generator's Name and Billing Address: <br /> Satellite Dialysis-Stockton Satellite Healthcare <br /> 590 E Harding Way 300 Santana Row*300 <br /> Stockton,CA 95204 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)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: 7.Transporter I.D.Numbers: <br /> Barnett Medical Services,Inc CALIFORNIA LISDOT# <br /> P.O. Box 4436,Hayward CA 94540 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-Modesto Barnett Medical Services-Modesto <br /> <br /> <br /> Permit <br /> 11.Description of Waste 12.Container Type(Quantity) 13.Welght(Lbs) <br /> UN3291,Regulated Medical Waste, N.O.S,6.2, PG 11 QR:99a6ac8 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste, N.O.S,6.2,PG 11 QR:99cf762 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG 11 QR:aa6bec3 40 gal Bio Disposal(1) 47.00 <br /> UN3291,Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:b7741a8 40 gal Bio Disposal(1) 47.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PIS 11 QR:c3c1e7e 40 gal Bio Disposal(1) 47.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:ce473b9 40 gal Bio Disposal(1) 47.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d669611 40 gal Bio Disposal(1) 47.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG 11 QR:e375b41 40 gal Bio Disposal(1) 47.00 <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 NO CUSTOMER SIGNATURE X CUSTOMER WAS UNAVAILABLE Date 06-14-2019 <br /> Signature Print Name <br /> 16)Barnett Medical Services, Inc CALIFORNIA <br /> X X Date 06-14-2019 <br /> Haulers Sianature Print Name <br /> 17)Discrepancy Indication Space: <br /> Software error. Signature was not uploaded Initials: SB <br /> Date:06/14/2019 <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 /> 06-14-2019 X <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X <br /> Print Name Print Name <br />