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Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS6.2UN3291 <br /> 9 Y <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 03-06-2018 1 54228-03-06-2018-015609-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 DTSC#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:170dd2b D03/08/2018 40 gal Bio Disposal(1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:1725535 D03/08/2018 40 gal Bio Disposal(1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:173c235 D03/08/2018 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:15dcOf3 D03/08/2018 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:16001dd D03/08/2018 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:161803c D03/08/2018 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:162f7f9 D03/08/2018 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:1646ccb D03/08/2018 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. �v <br /> 6/t\J\� WY���o <br /> XM/;� X Date 03-06-2018 <br /> Sig Print Name <br /> 16) Mrnett Medical Services, Inc CALIFORNIA <br /> 2 - <br /> X1112X Edrei Suarez (Driver) Date 03-06-2018 <br /> Ha lers S1'nat a Print Name <br /> 17) bscrepa6c dication 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"w rested In accordance with applicable legal requirements on the date <br /> indicated <br /> 03-06-2018 <br /> Signature Date Signature Date <br /> X BRETf ESPICHA X ESPICHA 1 1) ; 1 <br /> Print Name Print Name I 03/08/2018 1 <br />