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01 0 <br /> Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASSS-2 UNN91 <br /> Phone Number P.O. Box Hayward CA 94540 <br /> (925)321-5938 REGULATED MEDICA , WASTE TRACKING FORM <br /> 1.Generator's ID No.: IA. Generator's EPA No.: IB.Generator's DEA No.: 1Date: 2.Trackingform—Doc.No.: <br /> 39115-62763 07-16-2019 162763-07-16-2019-534019-BB <br /> 3.Generator's Name and Site s: <br /> 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 <br /> Code:(209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: 7.Transporter I.D. Numbers: <br /> Barnett Medical Services,Inc CAUFORNIA USDOT# <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----f—OAlteFn-ate—Treatmj7nt Facility <br /> BMS-Modesto Barnett Medical Services-Modesto <br /> <br /> <br /> <br /> 12, Container Type(Quantity) 13.Weight(Lbs) <br /> UN3291,Regulated Medical Waste,N.O-S,6.2,PG 11 QR:182babb D07/18/2019 40 gal 810 Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.0-S,6.2,PIG 11 QR:417da30 D07118/2019 40 gal Bio Disposal(1) 27.00 <br /> -UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:4c92flc 007118/2029 40 gal Bio Disposal(1) 27.00 <br /> c1ling Instructions and—Addition-al 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 07-16-2019 <br /> Signature Print Name <br /> 16)Barnett Medici!Services, Inc CALIFORNIA <br /> X X Date 07-16-2019 <br /> ljaulgr5 Signg-tt= PrinLBAme <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 certities that the waste documented <br /> on this'tracking*w reared <br /> in accordance with applicable legal requirements on the date <br /> Indicated <br /> 07-16-2019 <br /> Signature Date Signature Date <br /> X BRETT ESPICHAX BRETT ESPICHA <br /> MATEDI <br /> Print Name Print Name MOL2019 I <br />