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Emergency Barnett Medic-ii 'Services, IncCALIFORNIA RMW-CIASS6.2UN3291 <br /> Phone dumber P.O. Box 4436, Hayward CA 94540 <br /> (925)321-5938 REGULATED MEDICALTRACKING F <br /> 1. Generator's ID No.: 1A. Generator's EPA No.: 1B. Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 39115 - 5422 01-03-2020 54228-01-03-2020-280508-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:6d7de93 D01/07/2020 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:6d85e81 D01/07/2020 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N,O.S, 6.2, PG II QR:6d8e2fb D01/07/2020 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:6d95e30 D01/07/2020 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 /> Xo �� (� X Date 01-03-2020 <br /> Signature Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X _0X Miguel Corona Date 01-03-2020 <br /> Haulers S66ture Print Name <br /> 17) Discrepancy 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"w rea ed in accordance with applicable legal requirements on the date <br /> indicated <br /> 01-03-2020 <br /> Signature Date Signature Date <br /> X 5 IC X SIC 1 <br /> Print Name Print Name 1 01/07/2020 1 <br />