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0 0 <br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLA-SM2 U&W91 <br /> P u P.O. , <br /> 80, <br /> Phone Number -0- Box 4436, Hayward CA 94540 <br /> (926)321-5938 UL T B IV, <br /> REGULATED BIOMEDICAL WASTE TRACKING FORM <br /> D No.: 1A.Generator's 3 7 ITracking!''111 -;� <br /> 1.Generator's I r's EPA No.: 18.Generator's DEA No.: Date: <br /> 39115-62763 2 Form Doc.%No.: <br /> 10-08-2019 62763-10-08-2019-370610-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: -ZA:Generator's Billing Phone Number with Area Code: <br /> (209)774-5800 (650)404-3600 <br /> 6.Transporter Company Name: T ransporteF-1.17) lNumbers: <br /> Barnett Medical Services Inc CALIFORNIA LISDOT* <br /> P.O. Box 4436,Hayward CA 94540 DTSC*6183 <br /> (800)748-1803 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility-N-a—m-e-/A- dress— 167Xiteomate 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.Welght(Lbs) <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 OR:d65005f,Destroyed 10/09/203W gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d653bd8,Destroyed 10/09/2 X9 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR-.d6577e3,Destroyed 10/09/2 9 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG If QR:d65f190,Destroyed 10/09/21 29 gal Bio Disposal(1) 37.00 <br /> N3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d65b3d5,Destroyed 10/09/2)w gal Bio Disposal(2) 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 /> Date 10-08-2019 <br /> Sin atDett e ical Services Incre Print—-N- <br /> 6)Ba M cf� SE <br /> tcCALIFORNIA <br /> - <br /> X W X Marty Montez Date 10-08-2019 <br /> HijulgH Signature Print Name <br /> 17)V&kpancy Indication Space: <br /> Initials: <br /> R) <br /> Date: <br /> 18)Receipt of Materials Covered by this Manifest: 19 <br /> )Certificate of Destruction: The signature below certifies that the waste documented <br /> on this'tracking'w7v�Feafed in accordance with applicable legal requirements on the date <br /> indicated <br /> 10-08-2029 <br /> Date Signature Date <br /> X BRETT ESPICHA X BRETT ESPICHA <br /> I --- ---- 1 1)0,09(( 1219 <br /> Print Name Print Name <br />