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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 12-26-2016 54228-12-26-2016-490613-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-Stockton Barnett Medical Services Daniels Sharpsmart <br /> 2385 Arch Airport Rd 2385 Arch Airport Rd 4144 E Therese Ave <br /> Stockton,CA 95206 Stockton, CA 95206 Fresno, CA 93725 <br /> (510)240-1900 Permit#:TS/OST-106 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:9178cc7 D12/29/2016 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:919c231 D12/29/2016 40 gal Bio Disposal(1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:918a653 D12/29/2016 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:91ade8e D12/29/2016 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 X Date 12-26-2016 <br /> Sign tu Print Name <br /> 16) B ett Medic ervices, Inc CALIFORNIA <br /> X I X Miguel Aguilar Date 12-26-2016 <br /> Haulers Si Print Name <br /> 17) Dis y <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 /> r indicated <br /> G <br /> lluu 12-2V-2®16 <br /> Signature Date Signature Date <br /> X BRETT ESPICHA XBRETT ESPICHA I1)ESTROni, l <br /> Print Name Print Name I, 12— <br /> /29/2016 - I <br /> ® -- <br />