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Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS6.2UN3291 <br />Phone Number 3670 Enterprise Ave, Hayward CA 94545 <br />(510)429-9911 REGULATED MEDICAL WASTE TRACKING FORM <br />1. Generator's ID No.: <br />1A. Generator's EPA No.: <br />1B. Generator's DEA No.: <br />Date: <br />2. Tracking Form Doc. No.: <br />41411 - 57007 <br />03-30-2018 <br />57007-03-30-2018-201311-BB <br />3. Generator's Name and Site Address: <br />3A. Generator's Name and Billing Address: <br />ServPro of Stockton <br />ServPro of Stockton <br />2334 Stagecoach Rd <br />PO Box 422 <br />Stockton,CA 95215 <br />San Carlos,CA 94070 <br />4. Generator's Phone Number(s) with Area Code: <br />4A: Generator's Billing Phone Number with Area Code: <br />(209) 477-3090 <br />(209) 477-3090 <br />6. Transporter Company Name: <br />7. Transporter I.D. Numbers: <br />Barnett Medical Services, Inc CALIFORNIA <br />USDOT# <br />3670 Enterprise Ave, Hayward CA 94545 <br />EPA# CAL000403598 <br />(510) 429-9911 <br />DTSC# 6183 <br />8. Transfer Facility Name/Address: <br />9. Treatment Facility Name/Address <br />10. Alternate Treatment Facility <br />BMS- Stockton <br />Barnett Medical Services <br />Daniels Sharpsmart <br />2385 Arch Airport Rd <br />2385 Arch Airport Rd <br />4144 E Therese Ave <br />Stockton, CA 95206 <br />Stockton, CA 95206 <br />Fresno, CA 93725 <br />(510) 240-1900 Permit #:TS/OST-106 <br />Permit #:TS/OST-106 <br />(559) 834-6252 Permit #:TS/OST-55 <br />11. Description of Waste <br />12. Container Type (Quantity) <br />13.Weight (Lbs) <br />UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:4aOa733 <br />40 gal Bio Disposal (1) <br />15.00 <br />UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:4aldba2 <br />40 gal Bio Disposal (1) <br />15.00 <br />UN3291, Regulated Medical Waste, N.O.S, 6.2, PG II QR:49e2cb8 <br />40 gal Bio Disposal (1) <br />15.00 <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 0/�U�J �C� X Date 03-30-2018 <br />Signature Print Name <br />16) Barnett Medical Services, Inc CALIFORNIA <br />X X Marty Montez Date 03-30-2018 <br />Hauler /ia n Print Name <br />17) Discrepancy Indication Space: <br />Initials: <br />Date: <br />18) Receipt of Materials Covered by this Tracking Document: <br />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 />(_:,,9� ` �._.___.- 7 03-30-2018 <br />X <br />Signature Date <br />Signature Date <br />X BRETT ESPICHA <br />X <br />Print Name <br />Print Name <br />