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jAk AK <br /> Emergency BarMt Medical Services, Inc CALI RNIA RMW-CLASS6.2UN3291 <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.: IA.Generator's EPA No.: 113.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 39115-62763 106-14-2019 62763-06-14-2019-480217-BR <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)ose,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 /> B.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Modesto Biologics <br /> <br /> <br /> : Permit#: <br /> 11. Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) <br /> Non-Hazardous Pharmaceutical Waste QR:49b341a 3 gal Pharma Disposa...(1) (TBD) <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 Si nature 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 />