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t <br />Emergency Barnett Medical Services, Inc CALIFORNIA RMW-CLASS6.2UN3291 <br />Phone Number 3670 Enterprise Ave, Hayward CA 94545 <br />(510)429-9911 REGULATED MEDICAL WASTE TRACKING FORM <br />1. Generator's ID No.: <br />1A. Generator's EPA No.: <br />1B. Generator's DEA No.: <br />Date:2. <br />Tracking Form Doc. No.: <br />19115 - 54260 <br />1 1 <br />108-16-2016 <br />54260 -08 -16 -2016 -072713 -BR <br />Generator's Name and Site Address: <br />3A. Generator's Name and Billing Address: <br />Satellite Dialysis- Stockton <br />Satellite Healthcare <br />,3. <br />1801 E March Ln <br />300 Santana Row 300 <br />Stockton,CA 95210 <br />San Jose,CA 95128 <br />4. Generator's Phone Number(s) with Area Code: <br />4A: Generator's Billing Phone Number with Area Code: <br />(209) 473-6890 <br />(650) 404-3600 <br />6. Transporter Company Name: <br />7. Transporter I.D. Numbers: <br />Barnett Medical Services, Inc CALIFORNIA <br />USDOT# <br />3670 Enterprise Ave, Hayward CA 94545 <br />EPA# CAL000403598 <br />(510)429-9911 <br />DTSC# 6183 <br />8. Transfer Facility Name/Address: <br />9. Treatment Facility Name/Address <br />10. Alternate Treatment Facility <br />BMS- Stockton <br />Daniels Sharpsmart <br />2385 Arch Airport Rd <br />4144 E Therese Ave <br />Stockton, CA 95206 <br />Fresno, CA 93725 <br />(510) 240-1900 Permit #:TS/OST-106 <br />(559) 834-6252 Permit #:TS/OST-55 <br />Permit #: <br />11. Description of Waste <br />12. Container Type (Quantity) <br />13.Weight (Lbs) <br />Non -Hazardous Pharmaceutical Waste QR:3a3a8a9 D09114/2016 <br />3 gal Pharmaceutical (1) <br />8.00 <br />14) Special Handling Instructions and Additional Information: <br />Treatment System: <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 Date 08-16-2016 <br />Signature Print Name <br />16) Barnett Medical Services, Inc CALIFORNIA <br />X �/y X Marty Montez Date 08-16-2016 <br />Hauler signature Print Name <br />17) Discrepancy Indication Space: <br />Initials: <br />Date: <br />18) Receipt of Materials Covered by this Tracking Document: <br />08-16-2016 <br />19) Certificate of Destruction: Thesignature below certifies that the waste documented <br />on this °tracking,w reatcd In accordance wt h applicable legal requirements on the date <br />indicated i <br />, Vi _ __— <br />.iignature Date <br />Signature Date <br />X BRETT ESPICHA <br />XBRETT ESPICHA <br />Print Name <br />1„ES7ROYEllI <br />Print Name �� 09L14/2016 _.4 <br />