Laserfiche WebLink
Emergency Barn t Medical Services, Inc CALIOURNIA RMW-CLASS6.2UN3291 <br /> Phone Number 3670 Enterprise Ave, Hayward CA 94545 <br /> (510)429-9911 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1. Generator's ID No.: 1A. Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 44065-61283 05-31-2017 1 61283-05-31-2017-592013-BB <br /> 3. Generator's Name and Site Address: 3A. Generator's Name and Billing Address: <br /> Main Location East Main Tattoo <br /> 2008 E Main St 2008 E Main St <br /> Stockton,CA 95205 Stockton,CA 95205-5648 <br /> 4. Generator's Phone Number(s)with Area Code: 4A: Generator's Billing Phone Number with Area Code: <br /> (209) 351-6688 (209) 351-6688 <br /> 6.Transporter Company Name: 7.Transporter I.D. Numbers: <br /> Barnett Medical Services, Inc CALIFORNIA USDOT# <br /> 3670 Enterprise Ave, Hayward CA 94545 EPA# CAL000403598 <br /> (510)429-9911 DTSC# 6183 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Stockton Barnett Medical Services Daniels Sharpsmart <br /> 2385 Arch Airport Rd 2385 Arch Airport Rd 4144 E Therese Ave <br /> Stockton,CA 95206 Stockton,CA 95206 Fresno, CA 93725 <br /> (510)240-1900 Permit#:TS/OST-106 Permit#:TS/OST-106 (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 II QR:5f74eOb 20 gal Bio Disposal (1) 10.00 <br /> 14)Special Handling Instructions and Additional Information: <br /> Treatment System: <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 /> �/� <br /> )q"ygd <br /> X X Date 05-31-2017 <br /> Signatu a Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X q�� X Marty Montez Date 05-31-2017 <br /> H a u I e rA i ture Print Name <br /> 17) Discrepancy Indication Space: <br /> Initials: <br /> Date: <br /> 18) Receipt of Materials Covered by this Tracking Document: 19) Certificate of Destruction: The signature below certifies that the waste documented <br /> on this"tracking"was treated in accordance with applicable legal requirements on the date <br /> �— indicated <br /> i <br /> 05-31-2017 X <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X <br /> Print Name Print Name <br />