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Emergency Barnett Medical Services Inc CALIFORNIA RMWCLASM2 UN3291 Phone Number P.O. BOX 4436, Hayward CA 94540 (925)321-5938 REGULATED BIOMEDICAL WASTE TRACKING FORM 1.Generator's ID No.: IA.Generator's EPA No.: 1B.Generator's DEA No.: Date: 12.Tracking Form Doc. No.: 39115-54260 110-18-2019 54260-10-18-2019-215810-BB 3.Generator's Name and Site Address: 3A.Generator's Name and Billing Address: Satellite Dialysis-Stockton Satellite Healthcare 1801 E March Ln 300 Santana Row#300 Stockton,CA 95210 San jose,CA 95128 4.Generator's Phone Number(s)with Area Code: 4A:Generator's Billing Phone Number with Area Code: (209)473-6890 (650)404-3600 6.Transporter Company Name: 7.Transporter I.D. Numbers: Barnett Medical Services Inc CALIFORNIA USDOT# P.O.Box 4436,Hayward CA 94540 DISC*6183 (800)748-1803 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility BMS-Modesto Barnett Medical Services-Modesto Healthwise Services (925)321-5938 Permit#:TS/OST-106 (800)748-1803 Permit#:TS-107 (559)834-3333 Permit*:TS-89 11.Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) UN3291,Regulated Medical Waste,N.O.S,6.2, PG II QR:c750e00,Destroyed 10/21/2049 gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c74c390,Destroyed 10/21/2049 gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c7747a5,Destroyed 10/21/2 9 gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c776ce1,Destroyed 10/21/2U9 gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c771ff5, Destroyed 10/21/20 1.40 gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c76fae6,Destroyed 10/21/2 19)gal Bio Disposal(1) 37.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c76d4fa,Destroyed 10/21/2(3Z gal Bio Disposal(1) 37.00 14)Special Handling Instructions and Additional Information: 15)Generator's Certification: I hereby declare that the contents of this consignment are fully and accurately described above,and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. X X t Date 10-18-2019 Signatu Print Na 16)Ba i al Services Inc CALIFORNIA X X Marty Montez Date 10-18-2019 Ha i nature Print Name 17)Discrepancy Indication Space: Initials: Date: 18)Receipt of Materials Covered by this Manifest: 19)Certificate of Destruction: The signature below certifies that the waste documented on this-tracking-w rested in accordance with applicable legal requirements on the date indicated ,� 10-1$-2019 t ? Date Signature Date X BRETT ESPICHA XBRETT ESPICHA I I Print Name Print Name I 10 21 2019 I a.___L®��_�_.