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Emergency Barnett Medical Services Inc CALIFORNIA RMW-CIASS&2LJN3291
<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: 2.Tracking Form Doc.No.:
<br /> 39115-54260 1 1 110-22-2019 154260-10-22-2019-053309-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 /> 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:c7616c2, Destroyed 10/23/2049 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG Il QR:c7660d3,Destroyed 10/23/2040 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c763b9b,Destroyed 10/23/2 9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c779301, Destroyed 10/23/2 49 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c77dc96,Destroyed 10/23/2 49 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c782838,Destroyed 1023/2 9 gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:c78719f, Destroyed 10/23/2 IS gal Bio Disposal(1) 37.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:c78bbaa,Destroyed 10/23/2049 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 /> �2 ��e
<br /> X X Date 10-22-2019
<br /> Sip to Print Name
<br /> 16)B Tr�
<br /> Services Inc CALIFORNIA
<br /> X X Marty Montez Date 10-22-2019
<br /> Haulers Sionature 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 /> ( 10-22-2019 +"� --,
<br /> W414--i Date Signature Date
<br /> X BRETT ESPICHA XBRETT ESPICHA II
<br /> Print Name Print Name 191L;
<br />
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