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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 1 1 1 07-10-2018 1 54228-07-10-2018-051010-BR <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 t1SDOT# <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-Stockton Aemerge Repack <br /> 2385 Arch Airport Rd 9600 E Ave <br /> Stockton,CA 95206 Hesperia,CA 92345 <br /> (510)240-1900 Permit#:TS/OST-106 Permit#: Permit#: <br /> 11. Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) <br /> Non-Hazardous Pharmaceutical Waste QR:3737377 D10/08/2018 3 gal Pharma Disposa... (1) 8.00 <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 /> 0�//l) �1 v �( 4, <br /> X <br /> X �� Date 07-10-2018 <br /> Signature Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X X Marty Montez Date 07-10-2018 <br /> Hau s S tm&ure Print Name <br /> 17) Disc y In ication 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 /> 07-10-2018 <br /> Signature Date Signature Date <br /> X BRETT ESPICHA XBRETT ESPICHA I s' ' l 1)1 <br /> Print Name Print Name I 10/08/2018 <br />