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0 0 <br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLAS86.2 UN3291 <br /> Phone Number P.O. Box 4436, Hayward CA 94540 <br /> (925)321.5938 REGULATED BIOMEDICAL WASTE TRACKING FORM <br /> 1.Generator's-1—L)No.: IA.Generator's EPA NO.: iB.Generator's Date-- 2.Trakiiic —.: <br /> 62763 — <br /> 39115-62763 10-01-2019 1g Form Doc. No <br /> -10-01-2019-415709-BB <br /> 3.Generator's Name and Site Address: 3A.Generators 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 Code; <br /> (209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: 7.Transporter LD. 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/Address 9.Treatment--Facility Name/Address 10.Alternate Treatment Facility <br /> Barnett Medical Services-Modesto Bamett Medical Services- <br /> <br /> <br /> (559)834-6252 Permit*:TS/OST-55 <br /> 11. Description of Waste 12. Container Type(Quantity) -13.Welght(Lbs) <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d5d8a79, Destroyed 10/02/2 XG gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d5dl55e,Destroyed 10/02/2)49 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 011:20l:4851,Destroyed 10/02/2 40 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:20cc02e,Destroyed 10/02/2049 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG It QR:20d38ae,Destroyed 10/02/2 N1.9 gal Bio Disposal(1) <br /> 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 M?Xkal Services Inc CALIFORNIA <br /> � <br /> X X Marty Montes Date 10-01-2019 <br /> (ew��r Print NaLng <br /> 17)Discrepancy indication Space: <br /> Initials: <br /> Date: <br /> 18)Receipt of Materials Covered by this Manifest: 19)Certificate of Destruction: The signature Wow Certifies that the waste documented <br /> on this <br /> '"tracking":rea ad Lin accordance with applicable legal requirements on the date <br /> indicated <br /> Y-) > 10-01-2019 <br /> Date Signature Date <br /> X BRETT ESPICHA x BRETT ESPICHA <br /> n <br /> rit -- IDE <br /> ,Print Name PName0 02 2019 I <br />