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To: Page 2 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> I IN .930001EDICAL WASTE TRACKING FORM NUMBER <br /> .v Stericycle* CASE OF EMERG CY <br /> 3'�j FONYkF.CHEMTREC 1400-424 STANDnftWjJ(06-ST0 <br /> ft""New RFftftffiW Route #1. CUSTOMER N0.21-132 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN-.DaVe Kowalczyk 111111111 Mill <br /> QUEST DIAGNOSTICS <br /> 2291 W MRM LN BLDG F <br /> 5lroM=11, CA 95207- 6652 s/22/2016 <br /> (2tI9) 951-5831 <br /> CUSTOMER NUM111A 6019888-002 GENERAToFra REGISTRATION 0 <br /> 2A.DESCRIPTION OF WASTE 2B. CONIAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UNS291 Regulated Medilcal Wasik ac&. TBOS - 40 Gal Tub (Bio} (5.3 cu ft) CONTAINERS <br /> oil Poll Cu Ft <br /> UN3291 Regulated Mairleal Waste,fl.o's" TB49 - 37 Gal Tub (11110) (4.9 Cu tt) <br /> 6.2,PGIICu Ft, <br /> UN3291 110013lated Medhl (Vl �,Gal TU16010) (b-9 Ou Ll;r" <br /> 0 62,PH 114 �Y Cu FL <br /> UN3291 Regulated Medical Waste,rhos,, TZ21- <br /> .&2,PGII Cu R. <br /> uj UN8291 Regulated Medical Waste,aas., (U10) I-MC31-(Chway)3t 03'± Tdb(i-±415 "21 <br /> Z 0.2,PGI1 Cu Ft. <br /> UI Ual. TW(5- 1UUrT) <br /> 5 U118291 Regulated Medical Waste,fl.o.s., NB43-(Sio) <br /> 6.2.1`611 Cu PL <br /> UN3291,Regulated Medical Waste.n.os,. KRB— Z B5yjjtems Cat oar cu f1cl <br /> 6.21 PGII :LQCu Ft <br /> UN3291 Regulated Medical Waste,r4o--,, <br /> 62,P61i Co EL <br /> -ff1I Regulated Medical Waste,nA&, <br /> r,2!2 <br /> PG I Cu Ft- <br /> 3.Generator's Certification:'I hereby declare that the contents of this omignmerd are fully and accurately I S Po. 1 /77 Cu FL <br /> described o by the proper ah#lng name,and are clessifted,pacluallecl,marked and labelledtplacalged,a <br /> respsale n proper Condition for transport according to applicable international and natio M,'Piirntal OguilabonO <br /> OL <br /> !�L6 - ----- Z2 <br /> MP twTyped Name -- -----rtur)---- -- — U <br /> CC 4.fF-1ANSPaF-f-rFR—IADRtffi;�Cje' Inc Tbis is'a T�rugh' Shi;Zent Phone M. — - <br /> wAl,cft <br /> rx 4135 W. Swift Ave <br /> PPI tft,ptNMW 3400 <br /> 0 Fresno,CA 93722 <br /> CL <br /> a(a <br /> z TRANSPORTER Receipt of medical waste as described a <br /> x <br /> PrInt/Typs Nome_ Signature Date <br /> 5.INTERM18DIATE HANDLER 21 TRANSPORTER 2 ADORES S: Phone <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> Polintirrype Noma Signature, Date <br /> 13.*MRMMATS HANDLER 31 TRANSPORTER 3 ADDRESS. Phone 0. <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Print/Typs Namo Signature Dade <br /> 7.DISCREPANCY INDICATION <br /> rl GA.Pastlinalad Factirtr. 8e.Aftimate,Facility. ❑8C.Alternate F..hty.- <br /> Sha le,Inc. Stertcycle,Inc. <br /> Sbricycle.Inc. <br /> I 41315W.'M-AVO-C 90 N,FoxboroDrIvs 1651 Snelton DMA <br /> ti Fresno.0 7k North Set Lake.LJT 84054 Hollister,CA 95023 <br /> (888)783-7422 (889)783-7422 (986)783-7422 <br /> T!"OM 0 r. BA-448-JA-36 MOST 83 <br /> S17 <br /> TREATMENT F;ACJL1W.+c*FQfy that I have been authorized by the applicable state agency to accept untreated medical wastes and U1at I have <br /> cc received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br /> I.-P <br /> Prinoype Name signature Date <br />