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To: Page 3 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICAL WASTETRACKING FORM NUMBER <br /> 0®O ter iF e- fN i�� E�I�R�V80Ntlt$T:GNEtA3iiEC 1-600 A24 83QD STAB E0 To <br /> ° ft4c groapk, em: CUSTOMER NO,21132 <br /> ( <br /> I.Generator's Name,�A Aftband Tek8,h �CiorHIM <br /> aver QUEST DIAGNOSTIC$ <br /> 2291 W MARCS LN BLDG r <br /> STOCKTow, CA 95207— 6652 <br /> 6019888-002 <br /> CUSTOMER F UMM GmERATows Re aisTRAnaN If <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINER TYPE 2C.100.OF 20. VOLUME <br /> UN3291 RepladMedical Waste,n.o.s., TBOS — 40 Gal Tub (Bio) (5.3 au fig) CONTAINERS <br /> 6.2 PGi) Cu Ft. <br /> UN3291,Regulated Medial Waste,na's., <br /> 62,PGII c Cu fl <br /> 1110911 Cep salad M041cal Waste,n.o s., <br /> 0 6.2,1`611 — path TYIS—(Chemo)20 Gal Tuab(2.7CU ) Cu Fl. <br /> ,Q UNN32ff Regulated Medical Waste,n.a s., _ T Cu Ft <br /> uUN3� Regulated Mer6cal Waste,n.as., <br /> Z 6.2 PGf� Cu Ft. <br /> 71313132) <br /> t 3 612V3160 Regulated Med I Waste,nos., <br /> Cu R. <br /> UN32M Regulated Medical Waste,n.e.s, —. <br /> 6.2,1`611 Cu Ft. <br /> UN3291,Regulated Medical Waste,a as,6.2,PGICu Ft. <br /> UN3291 Regulated Medi Waste,nos., Ft <br /> 6.2.Fell Qu <br /> 3.Ganeratees Cortifilcationt"I hereby docrare that the contents of this consignment are fully and accurstaly TATA!.'i�► Cn,FL <br /> d by t a proper shipping name,and are Classified,packaged,marked and labeltedyplarded and <br /> al <br /> Ore peas in proMoondifilon for transport accord in to applicable international and natio ntai nagutad + 11' <br /> i 'P ad/fypad Na g tui fJL 6� <br /> NSPORTER 1 ADQftf@ 1CyrC1e' In TMS a roil Phone#. <br /> 4185 W. Swift Ve AWMHSIB"matao 3400 <br /> rresao,CA 93722 <br /> TRANSPORTER CEIRTIFICATIOlp Receipt of madicat waste as dascdbed a <br /> t <br /> Ptift a Name $lgrcatura Date <br /> 6.1NTEAMEDiATE HANDLER 2/TRANSPORTER 2 ADDRESS- Phone#. <br /> a Applicable PemNt Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Roceipt of madwal waste as described above <br /> PrtntfFype Now Signature Date <br /> A� L INTERMIVATC HANDLER 3/TRANSPOFITER 3 ADDRESS- Phone#. <br /> Applct:abre Farm&Numbers: <br /> INTERME=DIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of meocat waste as described above <br /> PdAVType Name Su alure Date <br /> 7.DISCREPANCY INDICATION <br /> A DealBnafoi Fae h: as.AiremAte F #ty: a0. r 80.Arternafe FacNtry <br /> Cyd) ,W. :'rCertdyc fnc. ;Inc. <br /> 4135 W. Ave 80 N.FoXboro Drive 1551 Shelton give <br /> P , , 1? North Sett lake,U'i' 84054 Hollister,CA 95M <br /> IC ( (888)783.7422 (866)7MT422 i <br /> a <br /> AUG 22 2D16 3A44a.,�s T8/0ST83 <br /> TREATMENT$ACM.ITY�,I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> F- received the a8o+7e"PR'et(cs�ed wastes in accordance with the requirement outlined in that authorization, <br /> 1 <br /> ?rk Vrypa'i+Pame Sin Data <br /> •� I <br /> cd <br /> m <br /> ORIGINAL. <br /> FP 1524 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />