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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CI.ASS6.2UN3291
<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.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc. No.:
<br /> 39115-54260 1 1 10-15-2019 54260-10-15-2019-325809-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 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 II QR:8b5b58c,Destroyed 10/16/2 46 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG Il QR:8b63831,Destroyed 10/16/2 ®gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8b6bicc,Destroyed 10/16/2 39 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG II QR:8b727d3,Destroyed 10/16/2 0gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8b79ec9,Destroyed 10/16/2040 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG II QR:8b5f396,Destroyed 10/16/2019 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:8b6743b,Destroyed 10/16/2 Ogal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8b6ecc9,Destroyed 10/16/2049 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
<br /> Date 10-15-2019
<br /> Signatur Print Name
<br /> 16) ical Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-15-2019
<br /> Haulers ature Print Name
<br /> 17)Discre 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 rested in accordance with applicable legal requirements on the date
<br /> indicated
<br /> 10-15-2019 s
<br /> At I Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA II
<br /> Print Name Print Name 10, 16(_2019 ^,;
<br />
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