|
0 -
<br /> Emergency Barnett Medical Services Inc CALIFORNIA RMWCLASS6.2UN3291
<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.: 1A.Generator's EPA No.: 16.Generator's DEA No.: Date: 2.Tracking Form Doc. No.:
<br /> 39115-54260 10-11-2019 54260-10-11-2019-482112-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 1.D. Numbers:
<br /> Barnett Medical Services Inc CALIFORNIA USDOT#
<br /> P.O. Box 4436,Hayward CA 94540 DTSC#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#: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 11 QR:8b40188,Destroyed 10/14/2 9gal Bio Disposal (1) 37.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8b38b9d,Destroyed 10/14/2)49 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8b13549,Destroyed 10/14/2 X9gal Blo Disposal(1) 37.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG II QR:8blae34, Destroyed 10/14/2 X0 gal Bio Disposal (1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6,2,PG II QR:8ble968, Destroyed 10/14/2 X9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8bl726b, Destroyed 10/14/2 X9gal Bio Disposal(1) 37.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2, PG II QR:8bOf9cf, Destroyed 10/14/20 L40 gal Bio Disposal(1) 27.00
<br /> 14)Special Handling Instructions and Additional Information:
<br /> 15)Generator's Certification:
<br /> 1 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 10-11-2019
<br /> Signa&j4eZ , Print Name
<br /> 16)Barne dical Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-11-2019
<br /> Hau r ature Print Name
<br /> 17)Discr p ncy 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 /> indicated ,ry
<br /> 1 ? �
<br /> 10-11-2019
<br /> Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA11)
<br /> Print Name Print Name I 1OLL L2019 ,�,
<br />
|