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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CLASS6.2UN3291 <br /> Phone Number P.O. BOX 4436, Hayward CA 94540 <br /> (926)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM <br /> 1.Generator's ID No.: 1'A.Generator's EPA No.: 1B.Generator's DEA No.: Date: 12.Tracking Form Doc. No.: <br /> 39115-54260 1 110-15-2019 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:8b762c0,Destroyed 10/16/2049 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8b7ddff,Destroyed 10/16/2 410 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:e30d3ff, Destroyed 10/16/20140 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:e31488f,Destroyed 10/16/20116 gal Bio Disposal(1) 37.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:e310e82,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 J Date 10-15-2019 <br /> Signatur Print Name <br /> 16)Mcal Services Inc CALIFORNIA <br /> X X Marty Montez Date 10-15-2019 <br /> Haulers ure 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 seated in accordance with applicable legal requirements on the date <br /> indicated <br /> } 10-152019 <br /> Date Signature Date <br /> X BRETT ESPICHA X BRETT ESPICHA tI <br /> Print Name Print Name 19=2L;6L?019 D 1 <br />