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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 08-04-2017 54228-08-04-2017-262510-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 DTSC# 6183 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Hayward Barnett Medical Services Daniels Sharpsmart <br /> 3670 Enterprise Ave 2385 Arch Airport Rd 4144 E Therese Ave <br /> Hayward, CA 94545 Stockton, CA 95206 Fresno, CA 93725 <br /> Permit#: 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:da6d67d D08/11/2017 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:da3e92b D08/11/2017 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:a5aa6df D08/11/2017 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:a58419e D08/11/2017 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:a5377f6 D08/11/2017 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:a55df08 D08/11/2017 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 08-04-2017 <br /> Signa a Print Name <br /> 16) Barnett Medical Services, Inc CALIFORNIA <br /> �Ha <br /> X David Aguilar Date 08-04-2017 <br /> S' r Print Name <br /> 17) iscrepa cy r d1 tion'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 /> i4s �� 08-04-2017 <br /> Signature Date Signature Date <br /> — -- -- <br /> x BRETT ESPICHA XBRETT ESPICHA I 1 <br /> Print Name Print Name 1 08/11/2017 1 <br /> %. -4 <br />