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0 0 <br /> Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS&2 VN3291 <br /> Phone Number P.O. Box 4436, Hayward CA 94540 <br /> (925)321.5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1.Generator's'l D- lqo.: IA.Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.:Tracking1I:'Form::' ................. No.: <br /> 39115-62763 07-19-2019 11 )Icz, <br /> 162763-07-19-2019-383118-BB <br /> 3.Generator's Name and Site 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 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- .�Transpoiter I.D.—Numbers: <br /> Barnett Medical Services,Inc CALIFORNIA USDOT* <br /> P.O.Box 4436,Hayward CA 94540 EPA#CAL000403598 <br /> (800)748-1803 DISC*6183 <br /> 8.Transfer Facility Name/Address: -9.—Treatment Facility-N—a—m-0/-A-d—dress —10.Alt-ernate'rreatiiTent Facility <br /> BMS-BMS-Modesto Barnett Medical Services-Modesto <br /> <br /> <br /> Permit <br /> 11,Description of Waste <br /> 12.Container Type(Quantity) :113:.Weight(Lbs) <br /> UN3291,Regulated Medical Waste, N.O.S,6.2,PG 11 QR:58e6848 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8d53801 40 gal Bio Disposal(1) 27.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:9a484c8 40 gal Bio Disposal(1) 27.00 <br /> LIN3291,Regulated Medical Waste,N.0.5,6.2,PG 11 QR:a75bd85 40 gal Bio Disposal(1) 27.00 <br /> 14)Special Handling Instructions and Additional information: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) arnettmedFcaIS—ervices,tilc-CAUFORN—IA <br /> X Date 07-19-2019 <br /> Haulers Sionature Print N <br /> 17)Discrepancy Indication Space: <br /> Software issues.SC Initials: SB <br /> Date:02LI�12020 <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 /> 07-19-2019 x <br /> Siignature Date Signature Date <br /> X BRETT ESPICHA X <br /> Print Name Print Name <br />