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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS62UN3291 <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.: 18.Generator's DEA No.: Date: 12.Tracking Form Doc. No.: <br /> 39115-54260 110-08-2019 54260-10-08-2019-572609-BR <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 Biologics <br /> 112 Spenker Ave 23490 Connecticut St <br /> Modesto,CA 95354 Hayward,CA 94545 <br /> (800)748-1803 Permit*:TS-107 Permit#: Permit#: <br /> 11.Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) <br /> Non-Hazardous Pharmaceutical Waste QR:8b225fa,Destroyed 11/29/2019 3 gal Pharma Disposa... (1) 8.00 <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 /> �f <br /> X I X Date 10-08-2019 <br /> Signa Print N <br /> 16)7Medical Services Inc CALIFORNIA <br /> X X Marty Montez Date 10-08-2019 <br /> HauleN Si natu a Print Name <br /> 17) i ancy 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"w reated in accordance with applicable legal requirements on the date <br /> j <br /> indicated I <br /> 10-08.2019 �, 1 <br /> Date Signature Date <br /> X RETT ESPICHAX BRETT ESPICHA I ES1110YE1 <br /> Print Name Print Name I,_®11L29�a ®.0 <br />