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Emergency Barnett Medical Services Inc CALIFORNIA RMw-CtASS6.2 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.: 1A.Generator's EPA No.: 16.Generator's DEA No.: Date: 12.Tracking Form Doc. No.:
<br /> 39115-54260 111-01-2019 54260-11-01-2019-485123-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#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 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
<br /> 112 Spenker Ave 112 Spenker Ave
<br /> Modesto,CA 95354 Modesto,CA 95354
<br /> (925)321-5938 Permit#:TS/OST-106 (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 11 QR:630828d,Destroyed 11/04/201M gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:7040794,Destroyed 11/04/20M gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG II QR:7ec3eOO,Destroyed 11/04/2 30 gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:8c9859a,Destroyed 11/04/2C 10 gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2, PG II QR:9d8bcdc,Destroyed 11/04/2 14D gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG 11 QR:afc20al, Destroyed 11/04/20 1.90 gal Bio Disposal(1) 40.00
<br /> UN3291,Regulated Medical Waste,N.O.S,6.2,PG Il QR:bbda837,Destroyed 11/04/2j=gal Bio Disposal(1) 40.00
<br /> UN3291, Regulated Medical Waste,N.O.S,6.2,PG Il QR:cee2310, Destroyed 11/04/2 1QD gal Bio Disposal(1) 40.00
<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 NO CUSTOMER SIGNATURE X CUSTOMER WAS UNAVAILABLE Date 11-01-2019
<br /> Signature Print Name
<br /> 16)Barnett Medical Services Inc CALIFORNIA
<br /> X X Date 11-01-2019
<br /> Haulers Si 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 reated in accordance with applicable legal requirements on the date
<br /> indicated
<br /> i
<br /> 11-01-2019
<br /> Date Signature Date
<br /> X BRETT ESPICHA X BRETT ESPICHA 11
<br /> Print Name Print Name I 11LQ4L2019 '�
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