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0 <br /> Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLAS36.2 UN3291 <br /> P u <br /> Phone Number R P.O. Box 4436, Hayward CA 94540 <br /> 1A_( <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 5 77 <br /> PA No.: Generator's <br /> 1.Generator's I 1A. DEA o.: Date; Form Doc.No.: <br /> 39115-62763 <br /> t es 07-16-201 �763-07-16-2019-534019-88 <br /> 3. <br /> Emergency <br /> Name and Site Address: 3A.Generator's <br /> Satellite Dialysis-Stockton tol ..g Address: <br /> Satellite Healthcare <br /> 590 E Harding Way 300 Santana Row#300 <br /> StDckton,CA 95204 San jose,CA 95128 <br /> 4.Generator's Phone Number(s)with Area—Code. 4A:Generators Billing Phone Number with Area Code: <br /> (209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name., 7.Transporter'l.D.Numbers: <br /> Barnett Medical Services,Inc CALIFORNIA USDOT# <br /> P.O. Box 4436,Hayward CA 94540 EPA#CAL000403598 <br /> (800)748-1803 OTS C*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 /> 107 Permit#: <br /> 11.Description of Waste <br /> 12.Container Type(Quantity) 13.Weight(Lbs) <br /> UN3291,Regulated Medical Waste,N.O.S.6.2:PG 11 QR:99129ad D07/18/2019 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:ba39ac3 D07/18/2019 40 gal 810 Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c875638 D07/18/2019 40 gal Bio Disposal(1) 22.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:d726ab3 D07/18/2019 40 gal Bio Disposal(1) 27.00 <br /> I <br /> UN3291,Regulated 1' <br /> Medical Waste,N.O.S,6.2,PG 11 QR:e3bd6c4 D07118/2019 40 gal Bio Disposal(1) 27.00. <br /> UN3291,Regulated medical Waste,N.O.S,6.2,PG 11 QR:f05b7ab D07/18/2019 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:fc8c43e 007118/2019 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:Ob5b9e5 D07/18/2019 40 gal Bio Disposal(1) 27.00 <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 I 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 07-16-2019 <br /> Signature Print Name <br /> 10-8amett Me icai Services,Inc CALIFORNIA <br /> X X Date 07-16-2019 <br /> -Hauln ur rinme <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 canines that the waste documented <br /> on this"tracidnq*w rea ad in accordance with applicable legal requirements on the date <br /> indicated <br /> 07-16-2019 <br /> — L-" <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X BRETT ESPICHA <br /> 1 <br /> 1)Z�=�I 32L 9 D, <br /> Print Name PFin—EName <br />