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0 <br /> Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS&2 UN3291 <br /> Phone Number P.O. Box 4436, Hayward CA 94540 <br /> Emergency <br /> Phone Numb-of <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1.Generator's 1 1A.-Generator's EPA No.: 111:11, (::i:!r1;:!rator's DEA No.: Date: 2 lri:11:161111 <br /> 39115-62763 g Form Doc, No.: <br /> 07-19-2019 62763-07-19-2019-383118-BB <br /> 3.Generator's NameandSite Address: 3A.Generator's Name and Billing Address: <br /> Satellite Dialysis-Stk Harding Satellite Healthcare <br /> 590 E Harding Way 300 Santana Row#300 <br /> Stockton,CA 95204 iSanaJose,CA95128 <br /> 4.Generator's Phone Number(s)With Area Code: 4A: Generators Billing Phone Number with AreTC—Ode. <br /> (209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: 7.Transporter I.D. Numbers: <br /> Barnett Medical Services,Inc CALIFORNIA USDOT# <br /> P.O. Box 4436,Hayward CA 94540 EPA#C61000403598 <br /> (800)748-1803 DTSC#6183 <br /> 8.Transfer Facility Name/Address: 'T—Treatment—Facility Name/Address 10.Afternate Treatment Facility_� <br /> BMS-Modesto Barnett Medical Services-Modesto <br /> <br /> <br /> 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 If QR:ed8ac15 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:f803fb6 40 gal Bio Disposal(1) <br /> 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:0633010 40 gal Bio Disposal(1) 27.00 <br /> UN3291.Regulated Medical Waste,N.O.S,6.2,PG 11 QR:1541d48 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:25b64c9 40 gal Bio Disposal(1) 27.00 <br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG 11 QR:31010ac 40 gal Bio Disposal(1) 27.00 <br /> U <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:3f6f70b 40 gal 810 Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:4b7766d <br /> 40 gal Bio Disposal(1) 27.00 <br /> 14)5 ectal Handlino-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 07-19-2019 <br /> -Signature- Print Name <br /> 16)Barnett Medical Services,IncCALIFORNIA <br /> X Date 07-19-2019 <br /> Haulers SignatUre Drint- Klz�?. <br /> 17)Discrepancy Indication Space: <br /> Software issues.SC Initials: SB <br /> Date:92LI2L2020 <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 /> a'191 07-19-2019 X <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X_ <br /> Print Name' Print Name <br />