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Emergency Barnett Medical Services Inc CALIFORNIA FAM-CLAM2t 291
<br /> Phone Number P.O. Box 4436® Hayward CA 94540
<br /> (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> 1.Generator's IL—)NO.: IA. Generator's EPA No.: 1B.Generator's DEA No.:I Date: 2.Tracking Form-—Doc.No.:
<br /> 39115-62763 --- ---- 110-04-2019 162763-10-04-2019-291210-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#300
<br /> Stockton,CA 95204 San jose,CA 95128
<br /> 77
<br /> 4.Generator's Phone Number(s)with Area Code: 4A:Generator's�Billing Phone Number with Area
<br /> (209)774-5800 (650)404-3600
<br /> 6.Transporter Company Name: 7.1riansporterl.D. Numbers:
<br /> I
<br /> Barnett Medical Services Inc CALIFORNIAUSDOT#
<br /> P.O.Box 4436,Hayward CA 94540 rDTSC*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 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 11 QR:d6If4c4,Destroyed 10/0712(IS gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated medical Waste,N.O.S,6.2,PG 11 QR:d609515,Destroyed 10107/2)itOgal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:20dccc,Destroyed 10/07/20140 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:20c83ec,Destroyed 10/07/2 ,39 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:20c0c4e,Destroyed 10/07/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d640e88,Destroyed 10/07/2 XQ gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d644af8,Destroyed 10/07/2(NO gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG If QR:d6394k,Destroyed 10/07/2C IS 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 /> C-)
<br /> X_ A— X— Date 10-04-2019
<br /> Sig ri-g-kt-twe Print N
<br /> 16)BgR"dica(Services Enc CALIFORNIA V1
<br /> X—-W X MaM Montez Date 10-04-2019
<br /> Haulers Sionature Print Namg
<br /> 17)Discrepancy 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"w7srfr—eattid in accordance with applicable legal requirements on the date
<br /> indicated
<br /> A 10-04-2019 6-(,M
<br /> Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA I MOTEDI
<br /> Print Name Print Name 10072019
<br />
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