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Emergency Barnett Medical Services Inc CALIFORNIA RMWCLASM2 UN3291
<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.: 1B.Generator's DEA No.: Date: 12.Tracking Form Doc. No.:
<br /> 39115-54260 110-18-2019 54260-10-18-2019-215810-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 DISC*6183
<br /> (800)748-1803
<br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility
<br /> BMS-Modesto Barnett Medical Services-Modesto Healthwise Services
<br /> 112 Spenker Ave 112 Spenker Ave 4800 E Lincoln Ave
<br /> Modesto,CA 95354 Modesto,CA 95354 Fowler,CA 93625
<br /> (925)321-5938 Permit#:TS/OST-106 (800)748-1803 Permit#:TS-107 (559)834-3333 Permit*:TS-89
<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:c750e00,Destroyed 10/21/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c74c390,Destroyed 10/21/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c7747a5,Destroyed 10/21/2 9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c776ce1,Destroyed 10/21/2U9 gal Bio Disposal(1) 37.00
<br /> 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
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c76fae6,Destroyed 10/21/2 19)gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c76d4fa,Destroyed 10/21/2(3Z 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 t Date 10-18-2019
<br /> Signatu Print Na
<br /> 16)Ba i al Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-18-2019
<br /> Ha i nature Print Name
<br /> 17)Discrepancy 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 /> ,� 10-1$-2019
<br /> t ? Date Signature Date
<br /> X BRETT ESPICHA XBRETT ESPICHA I I
<br /> Print Name Print Name I 10 21 2019 I
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