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To: Page 4 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> WEDICAL WASTE TRACKING FORM NUMBER <br /> Stericycle* IN CASE OF EMERGENCY CONTACT*CHIEMTREC I-SDD424-9300 STANDARD MANIFEST 001.10.06-STD <br /> W-09ftDARUMMOW Route #; 122 - 17 CUSTOMER NO.21132 M-I)FROO1566 <br /> I.Generator's Name,Address and Telephone Number <br /> ATTN:Dwim Kowalczyk <br /> QM-ST DIAGNOSTICS <br /> 2291 X MARCII LW BIDG 10 <br /> STOCKTOV, CA 95207- 6662 <br /> (209) 961-6831 8/8/2016 <br /> CUSTOMER NUMBER 6019888-002 Gamsixrows REawRATiou# <br /> 2A.DESCRIPTION OF WASTE 215. CONTAINER TYPE 2C.No.of 21), VOLUME <br /> "T Regulated Me loalwastp,B.G.S., TBOS - 40 Gal. Tub (Rio) (5.3 au. ft) CONTAINERS <br /> U <br /> poll Cu Ft <br /> UN341 Regulated Medical Waste,n,o.t, TB49 - 37 Gal tub (Bio) (4-9 C11 ft) <br /> 6.2,PGli Cu Ft <br /> itRoffulated Medical Waste,ii.o.s., TB14 - 44 Gal Tub(Bio) (5.9 CU It) le <br /> M13,11 Cu Ft <br /> UNS2 Regulated (Chemo)led Medical Waste. o.%, T921-(nxo)/TP15-(path)/TY15- ho)20 Gal TU2,11cupt) <br /> 6.2f POGII I Cu Ft. <br /> lu 8�14 I Rellulated Medial Waste It as <br /> Z WB31-(B;to)/WP31-(Patb)/WC31-(Cbemo)31 Gal Tub(4.14CUIT) <br /> Uj Cu Ft <br /> OWN,Regulated Medical Wage,ao's" WB43-(Rio)/Pb143-(Path)ICK43-(Ohamo) Gal TUb(5.'7cXXT) Cu Ft. <br /> 62 1.114%,RegulRegulatedMedical Wage,Bo.s, <br /> PGI KRR® - Biosystems Cardboard Box (4.2 cu tt) Cu Ft. <br /> EN4=1 Regulated Medical Waste,mo s., <br /> .5.21 PH CU Ft <br /> .6flP411 Regulated Moolost Wage,mo.%, Cu Ft <br /> 3.Qoneratorn Certification:'I hereby declare that the contents of this consignment are fully ancLa sly TOTALS <br /> Ell Vp ccurati 1-1 47 Cu R, <br /> Ili ialaa <br /> the proper shipping name,and are classified,packaged,marked and lab I r* ---- <br /> h proper <br /> s' 'r <br /> above the <br /> hipp ental regulations" <br /> I <br /> nag pacts <br /> p, d4lo�� at and national g <br /> eyl <br /> .P N <br /> dMiced .8hi, <br /> 4. N-6156RTER I ADDRESS: Phone#- (866)-183-702 <br /> Stericycle, Inc. 0 This 19 a Through Shipment Applicable permit Numbers, <br /> 4135 V. Swift Ave Hauler Regi 3400 <br /> Irresno,CA 93722 <br /> 0. TRANSPORTER-CERTIFICATION'-Receipt of medical waste as descr <br /> Prinirrype Name r -Signature Date <br /> S.INTERMEDIATE HANDLE FT2'1i?-TqSPORTER 2 ADD <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of mecow waste as described above <br /> PrInIf"Name Signature Data <br /> oil B.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS,. Phone <br /> Applicable Permit Numb*= <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt Of medical waste as described above <br /> PrInVrype N*me Signature DEW <br /> 7.DISCREPANCY INDMI70N <br /> ak Designated Fadilty; JU 613.Afternato Facift 6C.Alternate Facility: Aftemato FacloV. <br /> rtayC amu <br /> .WAC- 3baflcycte,Inc. Stericycle,Inc. <br /> 4135 W. 90 N.Foxboro 64 1651 Shelkin Drift <br /> Freano,CA 93722 North Set Lake,OF 84064 Hollister.CA 95023 <br /> T810 <br /> (866)M7qPR209 2016 (066)783-7422 (866)783-7422 <br /> I 3Ar44S%IA-36 I T8/OST 83 <br /> TREATMENT FACILITY:I cer*that I have been authorized by the applicable stale agency to accept untreated'medical wastes and that I have <br /> I-- received the above indicated wastes in accordance with the requirement outlined In that authorization. <br /> PfInItlYpe Name Trans!Wr—od Signature Date <br /> DRIGNAL <br />