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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS6.2UN3291
<br /> Phone Number R.O. BOX 4436, Hayward CA 94540
<br /> (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM
<br /> 1.Generator's ID No.: IA.Generator's EPA No.: 18.Generator's DEA No.: Date: 2.Tracking Form Doc.No.:
<br /> 39115-54260 1 1 110-01-2019 154260-10-01-2019-241909-BB
<br /> 3.Generator's Name and Site Address: 3A.Generator's Name and Billing Address:
<br /> Satellite Dialysis-Stockton Satellite Healthcare
<br /> 1801 E March Ln 300 Santana Row#300
<br /> Stockton,CA 95210 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)473-6890 (650)404-3600
<br /> 6.Transporter Company Name: 7.Transporter I.D. Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA USDOT#
<br /> P.O. Box 4436,Hayward CA 94540 DISC#6183
<br /> (800)748-1803
<br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility
<br /> Barnett Medical Services-Modesto Barnett Medical Services-Modesto Daniels Sharpsmart
<br /> 112 Spenker Ave 112 Spenker Ave 4144 E Therese Ave
<br /> Modesto,CA 95354 Modesto,CA 95354 Fresno,CA 93725
<br /> (800)748-1803 Permit#:TS-107 (800)748-1803 Permit#75-107 (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 11 QR:8a92f43,Destroyed 10/02/20L4110 gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG Il QR:8a9a724,Destroyed 10/02/2 YS gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8aaldbd,Destroyed 10/02/2 IS gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8aa976e,Destroyed 10/02/2(19)gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8abl8dd,Destroyed 10/02/2 M gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG li QR:8a96b47,Destroyed 10/02/2 M gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8a9e1f6,Destroyed 10/02/20140 gal Bio Disposal(1) 50.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:Baa5a95,Destroyed 10/02/2(}9)gal Bio Disposal(1) 50.00
<br /> 14)Special Handling Instructions and Additional Information:
<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
<br /> Date 10-01-2019
<br /> Si ature Print Name
<br /> 16)Barnett Mgdiral Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-01-2019
<br /> Haulev0sidriature Print Name
<br /> 17) Discrepancy Indication Space:
<br /> Initials:
<br /> Date:
<br /> 18)Receipt of Materials Covered by this Manifest: 19)Certificate of Destruction: The signature below certifies that the waste documented
<br /> on this"tracking"wreaRA in accordance with applicable legal requirements on the date
<br /> indicated � .�
<br /> > � 10-01-2019
<br /> t Y 2 Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA 1 I
<br /> Print Name Print Name I 1OL02L2019 ®,F
<br />
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