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Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLA556.2UN3291 <br /> Phone Number P.O. Box 4436, Hayward CA 94540 <br /> (925)321-5938 REGULATED MEDICAL WASTE TRACKING FORM <br /> 1.Generator's ID No.: lA.Generator's EPA No.: 1B.Generator's DEA No.: Date: 2.Tracking Form Doc. No.: <br /> 39115-54260 1 110-29-2019 54260-10-29-2019-190218-BB <br /> 3. Generator's Name and Site Address: 3A.Generator's Name and Billing Address: <br /> Satellite Dialysis-Stk March Ln Satellite Healthcare <br /> 1801 E March Ln #A 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 EPA#CAL000403598 <br /> (800)748-1803 DTSC#6183 <br /> 8.Transfer Facility Name/Address: 9.Treatment Facility Name/Address 10.Alternate Treatment Facility <br /> BMS-Modesto Barnett Medical Services-Modesto <br /> 112 SpenkerAve 112 Spenker Ave <br /> Modesto,CA 95354 Modesto,CA 95354 <br /> (800)748-1805 Permit#:TS/OST-107 (800)748-1803 Permit#:TS-107 Permit#: <br /> 11. Description of Waste 12. Container Type(Quantity) 13.Weight(Lbs) <br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG If QR:927b3b1 D10/30/2019 40 gal Bio Disposal(1) 40.00 <br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:a4ecObe D10/30/2019 40 gal Bio Disposal(1) 40.00 <br /> UN3291,Regulated Medical Waste, N.O.S,6.2, PG II QR:b2d9563 D10/30/2019 40 gal Bio Disposal(1) 40.00 <br /> 14 Special Handling Instructions and Additional Information: <br /> Treatment System: <br /> 15)Generator's Certification: <br /> 1 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 NO CUSTOMER SIGNATURE X CUSTOMER WAS UNAVAILABLE Date 10-29-2019 <br /> Signature Print Name <br /> 16)Barnett Medical Services, Inc CALIFORNIA <br /> X X Date 10-29-2019 <br /> Haulers Sianature Print Name <br /> 17)Discrepancy Indication Space: <br /> Initials: <br /> Date: <br /> 18)Receipt of Materials Covered by this Tracking Document: 19)Certificate of Destruction: The signature below certifies that the waste documented <br /> on this"tracking'w reated in accordance with Applicable legal requirements on the date <br /> indicated <br /> • a <br /> 10-29-2019 <br /> Signature Date Signature Date _ <br /> X BRETT ESPICHA X BRETT ESPiCHA <br /> Print Name Print Name 1 10 3L0220-192 1 <br /> .� _ ®� <br />