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0 <br /> Emergency Barnett Medical Services, Inc CALIFORNIA RMw-CtASS6.2 UN3291 <br /> Phone Number 3670 Enterprise Ave, Hayward CA 94545 <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1. Generator's ID No.: IA.Generator's EPA No.: 16.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 39263-54340 10 3Q 2019 54340-10-30-2019-193312-86 <br /> 3. Generator's Name and Site Address: 3A. Generator's Name and Billing Address: <br /> UPTOWN INK UPTOWN INK <br /> 3206 Pacific Ave 3206 PACIFIC AVE <br /> Stockton,CA 95337 Stockton,CA 95337 <br /> 4. Generator's Phone Number(s)with Area Code: 4A:Generator's Billing Phone Number with Area Code: <br /> (209)466-1200 (209)466-1200 <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 /> (800)748-1803 DTSC#6183 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Modesto Barnett Medical Services-Modesto Healthwise Services <br /> 112 Spenker Ave 112 Spenker Ave 4800 E Lincoln Ave <br /> Modesto,CA 95354 Modesto, CA 95354 Fowler,CA 93625 <br /> (925)321-5938 Permit#:TS/OST-106 (800)748-1803 Permit#:TS-107 (559)834-3333 Permit#:TS-89 <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:7252050 20 gal Bio Disposal(1) 15.00 <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 /> X X Date 10-30-2019 <br /> Sign ure Print N <br /> 16)Baw,ett Medical Services,Inc CALIFORNIA <br /> X-� X Marty Montez Date 10-30-2019 <br /> Haul eds-fa nature 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 /> i' indicated <br /> % r�,... 10-30-2019 <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X <br /> Print Name Print Name <br />