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<br /> Emergency Barnett Medical Services Inc CALIFORNIA RIAW-CLASSI).2 UN3291
<br /> Phone Number P.O. Box 4436, Hayward CA 94540
<br /> (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> 1.Generator's ID No.: 1A.Generator's EPA No.: no-enerator's DEA No.: Date: -- 12.Tracking Form Doc. No.:
<br /> .39115-62763 1 10-01-2019 62763-10-01-2019-415709-BB
<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#3D0
<br /> Stockton,CA 95204 San jose,CA 95128
<br /> 4.Generator's Phone Number(s)with Area Code: 4A:Generator's Billing Phone NumberwithArea Code:
<br /> (209)774-5800 (650)404-3600
<br /> 6.Transporter Company Name: 7,Tra'nsport-e-r-L.-D. Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA USDOT#
<br /> P.O.Box 4436,Hayward CA 94540 DTSC#6183
<br /> (800)748-1803
<br /> 8,Transfer Facility Name/Addres-s-: - ----9.Treatment Facility Name/Address 10.Alternate Treatment_Faiic I ity
<br /> Barnett Medical services-Modesto Barnett Medical services-Modesto Daniels Sharpsmart
<br />
<br />
<br /> (559)834-6252 Permit*:TS/OST-55
<br /> 11.Description of Waste 12.Container Type(Quantity)-- 13-Weight(Lbs)
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II OR:d5cda5f,Destroyed 10/02/2(38 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d5d4feB,Destroyed 10/02/2(112 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d5dc4db,Destroyed 10102/2 40 gal Blo Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S.6.2,PG 11 OR:d5e39db,Destroyed 10/02/2 A9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d5eb028, Destroyed 10/02/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:dSeea2f,Destroyed 10/02/2018 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste, N.O.S,6.2,PG 11 QR:d 5e7554,Destroyed 10/02/2 XQ gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:dSdffb3,Destroyed 10/02/20140 gal Bio Disposal(1) 37.00
<br /> 14)Special Handling Instructions and Additional Information:
<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 X Date 10-01-2019
<br /> Signature Print Name
<br /> 16)Barnett Mjal Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-01-2019
<br /> HaulpFQSi ture Print Name
<br /> 17)Discrepa6c—y Indication Space:
<br /> Initials:
<br /> Date:
<br /> 18)Receipt of Materials Covered by this Manifest: 19)Certificate of Destruction; The signature below certifies that the waste documented
<br /> on this-tracking'w rea ed in accordance with applicable legal requirements on the date
<br /> indicated
<br /> > J 10-01-2019
<br /> Date Signature Date
<br /> BRETT ESPICHA BRETT ESPICHA
<br /> X X II)EVMOYEDi
<br /> Print Name Print Name ;OLCL2L 01!L4
<br />
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