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<br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLA886.2UN32191
<br /> Phone Number P.O. Box 44361 Hayward CA 94540
<br /> (925)321.5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> 1.Generator's ONO.' 1A.Generator 1B,Generator's DEA No.: Date: -12—.Tracking Farm -.
<br /> Doc. No.:
<br /> 39115-62763 1 - 10-11-2019 162763-10-11-2019-123610-BB
<br /> 3.Generator's Name and Site Add 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 I.D. Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA LISDOT#
<br /> P.O.Box 4436,Hayward CA 94540 OTSC*6183
<br /> (800)748-1803
<br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/A-dJr—ess 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:d6667ee,Destroyed 10/1412 XG gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d66a807,Destroyed 10/14/2 XG gal Bio Disposal(1) 37.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d66e99e,Destroyed 10/14/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG If ORA67674a,Destroyed 10114/2 X9 gal Rio Disposal(1) 37.-00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d67dccc,Destroyed 10/14/2039 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d685199,Destroyed 10/14/2 X9 gal Rio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2.PG 11 OR:d68c95a,Destroyed 10/14/2049 gal Rio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d690407,Destroyed 10/14/2 X&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 /> X X Date 10-11-2019
<br /> SignatuF(e Print Narnie
<br /> 16) W Bar ild ical Services Inc CALIFORNIA
<br /> . X Marty Montez Date 10-11-2019
<br /> Haulgrs 51gne Pril2t NaLlIe
<br /> 17)Discrepancy Indication Space:
<br /> Initials:
<br /> Date:
<br /> 18)Receipt of Materials Covered by this Manifest:
<br /> 19)Certificate of Destruction: The signature below certilies that the waste documented
<br /> an this'tracking*w?,-f.—a—,.d in accordance with applicable legal requirements on the date
<br /> indicated
<br /> 10-11-2019
<br /> 66 if Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA
<br /> Print Name Print Name 1 =0L;4L?019
<br /> 1) D1—
<br />
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