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<br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS6.2 VN3 291
<br /> Phone Number P-0. Box 4436, Hayward CA 94540
<br /> (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> No.: I ;i;
<br /> 1.Generator's—ID N 1A.Generator's EPA No.: 1B.Generator's bETW57-7-T-D-a-t-e----------- 27. g11,Form I I I No.:
<br /> 39115-62763
<br /> 1 110-08-2019 162763-10-08-2019-370610-88
<br /> 3.Generator's Name and Site 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 /> 4.Generator's Phone Numtier(s)with Area C6d—e, 4A:Generator's Billing Phone Number with Area Code:
<br /> (209)774-5800 (650)404-3600
<br /> 6.Transporter Company Name: 7.Transporter I.D.Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA LISDOT#
<br /> P.O.Box 4436,Hayward CA 94540 DTSC#6183
<br /> (800)748-1803
<br /> 9.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
<br /> 12.Container Type(Quantity) 13.Weight(Lbs)
<br /> UN3291,Regulated Medical Waste,N-O-S,6.2,PIG It QR:d62306e,Destroyed 10/09/2 Xg gal Bio Disposal(1)
<br /> 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG If QR:d62a47f,Destroyed 10/09/2(=gal Bio Disposal(1)
<br /> 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d631c21,Destroyed 10/09/2)49 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PIS If QR:d626b23,Destroyed 10109/2),19gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2. PIS 11 QR:d62df33,Destroyed 10/09/2(19 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PIS 11 QR:d635917,Destroyed 10/09/2 X9 gal Bio Disposal(1)
<br /> 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d64c414,Destroyed 10/09/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG If OR:d648873,Destroyed 10/09/2)4LOgal 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
<br /> X Date 10-08-2019
<br /> Siqnzfure Print N
<br /> 16)BaDett Me ical Services Inc CALIFORNIA
<br /> XA1 X MaE!Y—Montez
<br /> Date 10-08-2019
<br /> Law&Kslcjnature Print Na
<br /> 7)
<br /> 11�iwancy Indication Space: —
<br /> Initials:
<br /> Date:
<br /> '18)Receipt of Materials Covered by this Manifest: —19)Certificate of Destruction: The Signature below certifies that thdocumented
<br /> waste
<br /> on this"tracking' d in accordance with applicable legal requirements on the data
<br /> Indicated wrrrewe
<br /> 10-08-2019
<br /> Date Signature Date
<br /> X BRETT ESPICHA
<br /> XBRETT ESPICHA
<br /> Print Name Print�Name
<br /> IM92019-1-0
<br /> V----
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