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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 01-05-2017 1 54228-01-05-2017-395813-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 USDOT# <br /> 3670 Enterprise Ave, Hayward CA 94545 EPA#CAL000403598 <br /> (800) 748-1803 DTSC# 6183 <br /> B.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Stockton Daniels Sharpsmart Daniels Sharpsmart <br /> 2385 Arch Airport Rd 4144 E Therese Ave 4144 E Therese Ave <br /> Stockton,CA 95206 Fresno, CA 93725 Fresno, CA 93725 <br /> (510) 240-1900 Permit#:TS/OST-106 (559)834-6252 Permit#:TS/OST-55 (559) 834-6252 Permit#:TS/OST-55 <br /> 11. Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) <br /> Non-Hazardous Pharmaceutical Waste QR:e3b01dd D02/10/2017 3 gal Pharma Disposa... (1) 3.00 <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 /> Sa�dv�\���-�.-4e. <br /> X 4 � X Date 01-05-2017 <br /> Signature Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> X X Miguel Aguilar Date 01-05-2017 <br /> Haulers ' ature Print Name <br /> 17) 7V5:§ pa: <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 reated in accordance with applicable legal requirements on the date <br /> indicated <br /> &A, 01-05-2017 + <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X TT ESPICHA I <br /> Print Name Print Name I 02/10/2017 I <br />