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To: Page 6 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> -"E6RCKL WASTE TRACKING FORM NUMBER <br /> WCASE OFIMEIGE�CY CONTACT:CHEMTREC 1-000-424-MMW MNDARD MANIFEST 001-10.06-SM <br /> ®® <br /> SteriFycle, - 15 <br /> NOW41*811M Routs CUSTOMER NO.21132 MDFROOI39? <br /> 1.Generator's NaMe,Address and Telephone Number <br /> ATTN.-Dave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 IR MR= LN BLDG r <br /> ISTOCN 'Br cM 95207- 6662 (209) 951-6831 7/25/2016 <br /> CUSTOMER NUMBER 6019888-002 Getuinxrows ReousmATION# <br /> 2A.DESCRIPTION OF WASTE 28. CONIZAINERTYPE 2C.NO.OF 20. VOLUME <br /> Ulliml,Regulated medical Waste, TB05 - 40 Gal Tub (BiO) (5.3 Cut ft) CONTAINERS <br /> c?,PGII Cu Ft <br /> UN3M Regulated Medical Waste.n.o,s,, Too - 37 Ga Tub (Bio) (4.9 cu ft) <br /> 62,0611Cu Fl <br /> M LMM Regulated Medical Waste,n.o,s,, TU14 - 44 Gal 'Tub (5.9 CU, It) <br /> 0 6.2.PGII L3 I -. -) Cu Ft. <br /> !� =91 Regulated Mfulkat Waste,nms, TB21-(8Xo)/TE,15-(Fath)1T5 5-(ditsao)20 Gal TUb(2.7CUE <br /> tc 62,PGII --- Cu Ff. <br /> W UN3291 Regulated Medical A, rgB3l-(Rio)lVp3l-(pitth)/WC31-(chemo)31 Gal Tub(4.14CUFr) <br /> Z 62,Pali Cu Ft <br /> tu <br /> UN= Regulated Mer4—Waste.0AS" WB42-(Bio)/L*W43-(path) CW (Chemo) Gal Tub(S.7CUPT) <br /> 62.Pa1li Cu Ft. <br /> UK'3291 Regulated Medical Waste.was., xRB - BioWartemsar <br /> Cardboard Box (4.2 Cu 'Et)0.2.PQ11 Cu Ft. <br /> UN 911 Regulated Medical Waste,n o a. <br /> 62,P611 CU Ft. <br /> UN3291,Regulated Medical Waste,n o a, <br /> 6,2,PGII CuFt- <br /> &awarators CorlIfication:'I hereby declare that the contents of this consignment are fully and accurately 7WALS` 4 Cu Ft. <br /> r d above by the proper shippMg narne,and are classified,paclago,marked and labelled/ I orded and <br /> 1(a W respects In proper condition for tmWort according to applicable International and nab m tall regulations* <br /> *ipej <br /> X la&Typed Nisine WODA �IWHAILL <br /> 4.MMNSPORTER I ADDRESS: japant Phone# MW783-74CTZ <br /> x [3 Trds Is a Through S <br /> Lu Stec ler Xnc. Applicable Permit Numbers: <br /> 21-6 4135 W. Swift Ave nattLer Reg# 3400 <br /> !�0 <br /> rreano,ch 93722 <br /> 1L TRANSPORTER I RTIFIGATIQN:Receipt of medical waste as dsscnQ( <br /> Prk*Type Name Signature Date <br /> S,INTERMEDIATE RAN16LER 2/TRANSPORTER 2 ADDRESS. Phone <br /> Applicable Patent Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION!Receipt of medical waste as described above <br /> PrInVilype Name Signature Date <br /> IIs s 6.1 NTERMEDLqE HANDLER 3l TRANSPORTER 3 ADDRESS: Phone <br /> Applicable Permit Numbers, <br /> be <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as dosentiod abovit, <br /> PrjnVWa Name Signature Date <br /> 7.DISCREPANCY—RDR-AnoN <br /> —4 - <br /> .j WA.Designated Facility: 8%Alternate Fbol!]W. ❑80.Afternate FaclW. E]aD.Aftemate Facility: <br /> —M=s.kllc� S�i Is.Inc. Staftcle,Inc. <br /> N <br /> 4135 W.SWMA EORTIZ Fo6cm DMO 1551 Shaftn Drift <br /> Presno.CA 93122 North Sint Lake.UT 840% HaIllster,CA 95M <br /> (869)783-74 2 (811)114" (866)783-7422 <br /> TA 26 2916 3A-448-JA-96 T9/0ST83 <br /> FAC1LA4fVWr I I <br /> TREATMENTI .Irthd I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above indicated wastes In accordance with the requirement outlined in that authorization. <br /> P*VrYPQ Nam* Date <br /> Transbrivill cant em' CU ft tb <br /> ORIIGINAL <br />