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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 12-07-2017 1 54228-12-07-2017-175207-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-Stockton Barnett Medical Services <br /> 2385 Arch Airport Rd 2385 Arch Airport Rd <br /> Stockton, CA 95206 Stockton, CA 95206 <br /> (510) 240-1900 Permit#:TS/OST-106 Permit#:TS/OST-106 Permit#: <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:baf3994 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bb2dee6 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:bb5c52f 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bb89a91 40 gal Bio Disposal (1) 30.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:bb9db5c 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bb715fa 40 gal Bio Disposal (1) 40.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG 11 QR:bb474be 40 gal Bio Disposal (1) 50.00 <br /> UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:bb18101 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 I X �✓ Date 12-07-2017 <br /> Signatu4p Print 1\18`6e <br /> 16) Barne A <br /> X X Rob Pletcher Date 12-07-2017 <br /> Hauler Print Name <br /> 17) Dis p ica i n pac <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"was treated in accordance with applicable legal requirements on the date <br /> indicated <br /> ( 12-07-2017 X <br /> Signature Date Signature Date <br /> X BRETT ESPICHA X <br /> Print Name Print Name <br />