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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS6.2UN3291
<br /> Phone Number P.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.: 16.Generator's DEA No.: Date: 12.Tracking Form Doc. No.:
<br /> 39115-54260 10-04-2019 54260-10-04-2019-432911-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.O. Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA USDOT#
<br /> P.O. Box 4436,Hayward CA 94540 DTSC#6183
<br /> (800) 748-1803
<br /> B.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 SpenkerAve 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#:TS-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 II QR:8a6dlaa,Destroyed 10/07/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste, N.O.S,6.2, PG II QR:8a70db0,Destroyed 10/07/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8ab9552,Destroyed 10/07/2 X9gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8ac0e90,Destroyed 10/07/21049 gal Bio Disposal(1) 37.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG II QR:8ac87ab,Destroyed 10/07/21049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8acffeb, Destroyed 10/07/20 40 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste, N.O.S,6.2, PG II QR:8ad74c2,Destroyed 10/07/2 90 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8adae5a,Destroyed 10/07/2 0 gal Bio Disposal(1) 37.00
<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 Date 10-04-2019
<br /> Sig ur Print N e
<br /> 16) ical Services Inc CALIFORNIA
<br /> X t;TX Marty Montez Date 10-04-2019
<br /> Haulers Si nature 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' rested in accordance with applicable legal requirements on the date
<br /> indicated
<br /> XI
<br /> V 10-04-2019
<br /> t r. Date Signature Date
<br /> X BRETT ESPICHA XBRETT ESPICHA ! " !
<br /> Print Name Print Name I 10 07 2019 I
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