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Emergency Barnett Medicilill Services, Inc CALIFORNIA RMWCLASS62UN3291
<br /> Phone Number P.O. Box 4436, Hayward CA 94540
<br /> (925)321-5938 REGULATED MEDICALTRACKING FORM
<br /> 1. Generator's ID No.: 1A. Generator's EPA No.: 16. Generator's DEA No.: Date: 2.Tracking Form Doc. No.:
<br /> 39115-54228 12-17-2019 1 54228-12-17-2019-554511-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 /> P.O. Box 4436, Hayward CA 94540 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-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 /> (800) 748-1805 Permit#:TS/OST-107 (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 II QR:7a9d838 D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:7aa4e68 D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:7aac588 D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:7ab4a27 D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:7abcl7b D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:7aal407 D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:7aa89ff D12/19/2019 40 gal Bio Disposal (1) 50.00
<br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:7ab0222 D12/19/2019 40 gal Bio Disposal (1) 50.00
<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 12-17-2019
<br /> Sig ure Print Name
<br /> 16) Barnett Medical Services, Inc CALIFORNIA
<br /> X X Marty Montez Date 12-17-2019
<br /> Hauler n e Print Name
<br /> 17) Discr a I ' ation 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"7:7 with applicable legal requirements on the date
<br /> indicated
<br /> y 12-17-2019 " z
<br /> Signature Date Signature Date
<br /> X ESPICHA X ESPICHA I 7 �
<br /> Print Name Print Name ,�12/19/2019
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