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<br /> Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLAS56.2 UN3291
<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.: 1A.Generator's EPA No.: is.Generator's'DEA No.: Date: '----T2.Tracking Form Doc.No.:
<br /> 139115-62763 1 110-41-2019 162763-10-11-2019-123610-BB
<br /> 3.Generators 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 /> 4.Generator's Phone Number(s)with Area Code: 4A:Generator's Billing Phone Number-with Area-C-ode.
<br /> (209)774-5800 (650)404-3600
<br /> 6.Transporter Company Name: 7,Transporter I.D. Numbers--:
<br /> Barnett Medical Services Inc CAUFORNIA USDOT#
<br /> P.O. Box 4436,Hayward CA 94540 DTSC#6183
<br /> (800)748-1803
<br /> 8'lmn—sferFacility Name/Address:- 9,Treatment Facill-t—yN-ame/Address 10.Alternate Treatment FR7117"
<br /> Barnett Medical Services-Modesto Barnett Medical Services-Modesto Daniels Sharpsmart
<br />
<br />
<br /> (559)834-6252 Permit#:TSIOST-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:d688c3b,Destroyed 10/14/2040 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d681712,Destroyed 10/14/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d67a240,Destroyed 10/14/2 @gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 ORA672a32,Destroyed 10/14/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d6b5f6a,Destroyed 10/14/2039 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d6b24c3,Destroyed 10/14/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:d6aea34,Destroyed 10/14/2 X9 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 /> Si nate Print Name
<br /> 16) ical Services Inc CALIFORNIA
<br /> X- W X a Montez Date 10-11-2019
<br /> -Haulers 5ignaturg Print NaMe
<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 d"umented
<br /> on this'tracking,wrl,—,eafed in accordance with applicable legal requirements on the date
<br /> Indicated
<br /> 10-11-2019
<br /> Date Isignature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA
<br /> 11) 2
<br /> Print Name Print Name �L;M4L;0 9 D
<br /> ki;— !-- — ----a
<br />
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