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Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS6.2UN3291
<br /> Phone Number 3670 Enterprise Ave, Hayward CA 94545
<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 /> 39115-54228 02-06-2018 1 54228-02-06-2018-543009-BB
<br /> 3. Generator's Name and Site Address: 3A. Generator's Name and Billing Address:
<br /> Satellite Dialysis-Tracy Satellite Healthcare
<br /> 2156 W Grant Line Rd 300 Santana Row 300
<br /> Tracy,CA 95377 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) 832-4899 (650)404-3600
<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 DISC# 6183
<br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility
<br /> BMS-Hayward Barnett Medical Services Daniels Sharpsmart
<br /> 3670 Enterprise Ave 2385 Arch Airport Rd 4144 E Therese Ave
<br /> Hayward,CA 94545 Stockton,CA 95206 Fresno, CA 93725
<br /> Permit#: 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:declbl3 D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:de9c3c2 D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:deaef2d D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:de86fc4 D02/07/2018 40 gal Bio Disposal(1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bdc4067 D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:d56c9f8 D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bddbaa6 D02/07/2018 40 gal Bio Disposal (1) 40.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:bdacd67 D02/07/2018 40 gal Bio Disposal (1) 40,00
<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 rl A - C,-)— I,rll X Date 02-06-2018
<br /> Sig r Print Name
<br /> 16) Barnett Medical Services, Inc CALIFORNIA
<br /> XX Luis Vallejo Date 02-06-2018
<br /> Ha lers Si at re Print Name
<br /> 17) ancy Indication e:
<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"w reated in accordance with applicable legal requirements on the date
<br /> indicated
<br /> � -- 0206-2018
<br /> Signature Date Signature Date
<br /> X BRE1T ESPICHA XBRETT ESPICHA MESTROYE 1
<br /> Print Name Print Name 02/07/2018 1
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