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Emergency Barnett Medical Services, Inc CALIFORNIA RMw•CLASS&2 UN3291 Phone Number P.O. Box 4436, Hayward CA 94540 (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM 1.Generator's ID No.: 1A.Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: 39115-54260 110-29-2019 54260-10-29-2019-190218-BB 3.Generator's Name and Site Address: 3A.Generator's Name and Billing Address: Satellite Dialysis-Stk March Ln Satellite Healthcare 1801 E March Ln #A 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 EPA#CAL000403598 (800)748-1803 DTSC#6183 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility BMS-Modesto Barnett Medical Services-Modesto 112 Spenker Ave 112 5penker Ave Modesto,CA 95354 Modesto,CA 95354 (800)748-1805 Permit#:TS/05T-107 (800)748-1803 Permit#:TS-107 Permit#: 11. Description of Waste 12.Container Type(Quantity) 13.Weight(Lbs) UN3291,Regulated Medical Waste, N.O.S,6.2,PG 11 011:13af03a D10/30/2019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:226b213 D10/30/2019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste, N.O.S,6.2, PG II QR:30bc667 D10/30/2019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:3e8c286 D10/302019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste, N.O.S,6.2, PG it QR:4cad2e5 D10/30/2019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:6979ab7 D10130/2019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste, N.O.S,6.2,PG II QR:764ed5d D10/3012019 40 gal Bio Disposal(1) 40.00 UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:84c6a4b D10/302019 40 gal Bio Disposal(1) 40.00 14 Special Handling Instructions and Additional Information: Treatment System: 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 NO CUSTOMER SIGNATURE X CUSTOMER WAS UNAVAILABLE Date 10-29-2019 Signature Print Name 16)Barnett Medical Services,Inc CALIFORNIA X X Date 10-29-2019 Haulers Si nature Print Name 17)Discrepancy Indication Space: Initials: Date: 18)Receipt of Materials Covered by this Tracking Document: 19)Certificate of Destruction: The signature below certifies that the waste documented on this"tracking'w reated in accordance with applicable legal requirements on the date indicated 1 r: Signature-'1 Date Signature i Date n.re.w.we.weswwewew,enwww�ne..n.y� X BRETT ESPICHA X BRETT ESPICHA I Print Name Print Name I 10 30 2019DII