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0 0 <br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CIA356.2 UNM1 <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.: IA.Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc, No.: <br /> 391_15-62763 10-04-20 2763-10-04-2019-291210-SR <br /> 3 <br /> 3.Generator's Name and Site Address: 7A.—Generatoris Name and Address: <br /> S <br /> Satellite Dialysis-Stockton Satellite Healthcare <br /> 5 <br /> 590 E Harding Way <br /> S S 300 Santana Row#300 <br /> tockton,CA 95204 San jose,CA 95128 <br /> 4.Generator's Phone Numbers)withAreaCode: 4A:Generator's Billing Phone Number with Area—code, <br /> (209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: T Transporter 1.0.Numbers: <br /> Barnett Medical Services Inc CALIFORNIA LISDOT# <br /> P.O. Box 4436,Hayward CA 94540 DTSC#6183 <br /> (800)748-1803 <br /> 6.Transfer Fac ilW-Name/Address: 9.Treatment—Facility-Name/Address 10.Alternate Treatment Facility <br /> BarnettBarnett Medical Services-Modesto Biologics <br /> <br /> <br /> : Permit <br /> 11.Description of Waste 12.Container Type(Quantity) 13-Weight(Lbs) <br /> Non-Hazardous Pharmaceutical Waste QR:d63d2c5,Destroyed 11/29/2019 3 gal Pharma Disposa...(1) 8.00 <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 V X Date 10-04-2019 <br /> Sin p Print N e <br /> 16)B dical Services Inc CALIFORNIA V/ <br /> X - __ X Marty Montez Date 10-04-2019 <br /> tLaulers SianaUrj Print NaMC <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'wIsIr—eated in accordance with applicable legat requirements on the date <br /> indicated <br /> i <br /> Print <br /> 10-04-2019 <br /> t <br /> Date Signature Date <br /> BRETT ESPICHA BRETT ESPICHA ——————————- <br /> X X I)E 81110YE I <br /> tPrint Name Print ma—me ki <br /> I %.-- maqw-01a.'T, <br />