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Emergency Barnail Medical Services, Inc CALL NI RMW-CLASS6.2UN3291 <br /> Phone Number 3W Enterprise'Ave, I'layward CA 94IW5 <br /> (925)321-5938 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 /> 39715 -54921 104-04-2019 54921-04-04-2019-371209-BB <br /> 3, Generator's Name and Site Address: 3A. Generator's Name and Billing Address: <br /> WINE COUNTRY CARE CENTER WINE COUNTRY CARE CENTER <br /> 321 W Turner Rd 321 W Turner Rd <br /> Lodi,CA 95240 Lodi,CA 95240 <br /> 4. Generator's Phone Number(s)with Area Code: 4A: Generator's Billing Phone Number with Area Code: <br /> (209) 334-3760 (209) 334-3760 <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 Daniels Sharpsmart <br /> 112 Spenker Ave 112 Spenker Ave 4144 E Therese Ave <br /> Modesto, CA 95354 Modesto, CA 95354 Fresno, CA 93725 <br /> (800) 748-1805 Permit#:TS/OST-107 (800) 748-1803 Permit#:TS-107 (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:087fbfe 40 gal Bio Disposal (1) 20.00 <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 04-04-2019 <br /> Signature Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X X Miguel Corona Date 04-04-2019 <br /> Hauler t Print Name <br /> 17) Discreponcy 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 /> --7 04-04-2019 X <br /> Signature Date Signature Date <br /> X BRETI' ESPICHA X <br /> Print Name Print Name <br />