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To: Page 7 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> deal <br /> EDICAL WASTE TRACKING FORM NUMBER <br /> STANDARD MANIFEST OM-10-0"TD <br /> *so RN CASE OF EMERGENCY COjrtCTCH9MTREC 1-BDO-424-N* <br /> Stencycleo <br /> Route #: 122 - CUSTOMER NO.21132 MDFROO12CO <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dave Kowalczyk tf <br /> QUEST DIAGNOSTICS <br /> 2291 N MARCH LN BLDG F <br /> STOOMN, CA 95207- 6652 <br /> (209) 951-5831 7/18/2016 <br /> 60199 88-002 GeNeRATOR'S REGISTPATION# <br /> 2A.DESCRIPTION OFWASTE 20. CONTAINER TYPE 2C.NO.Of 20. VOLUME <br /> CONTAINERS <br /> U1113291,Regulated Medical waste,Q,o.s;, T505 - 40 Gal Tub (Bio) (5.3 cu ft) Cu Ft. <br /> 6.2,PGII <br /> UN3291 Regulated Medical,We*,n a&, TB49 - 37 Gal Tub (Bio) (4.9 cu ft) <br /> 8,2.PGII Cu Ft. <br /> CC UMt Regulated Medical Waste,n o s., TB14 - 44 Gal Tub(Bio) (5.9 CU %t) <br /> 0 6.2,PGII t Cu Ff <br /> UNMI i Resided Medical Waste,mo s., T021-(210)/TP15-(Path)IVY15-(Chemo)20 Gal (2.7Dur v <br /> 6.2,PGI Cu Ft <br /> W UN3291 Moulded Medical Wasta,a o a., WB31-(B:Lo)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14CUFe) <br /> Z 62,PGII Cu Ft <br /> LU B.P PGII—Regulated Medical Wasta,cos., 1OB42-(Bio)/PW43-(Path)/CK43-(Chemo) Gal Tub(S.70UPT) <br /> Cu PL <br /> UN341 Regulated Medical Waste,n.o--,. ARB Bi*systems Cardboard Box (4-2 CU ft) <br /> 6.2,PGII FL <br /> 1111= Regulated Medal Waste.fto.s. <br /> 61,pa1ll Cu FL <br /> LL43291 RegulatedMadicalWasle,mos., <br /> 5.2.1`811 Cu Ft <br /> 3,Generators certification:11 hereby declare that the contents of this consignment are fully and accurately TOTALS 10. 1? -7 Cu Ft <br /> (d Y <br /> i0plils Idy the proper slopping name,and am classified.packaged,marked and label, pia d <br /> alltln "rpridiflon for transport acoording to applicable International and me tions" <br /> 6 is r - <br /> arna S <br /> hay'�Le W <br /> 4, PORTER I ADDRESS: P a# 7422 <br /> Wle' Inc. This; is Through $1-4pen <br /> Stec, Applicable Permit Numbers; <br /> 4135 W. Swift Ave 1Re *116 Fresno,CA 93722 Rauler g 3400 <br /> Z_C <br /> C6 TRANSPORTER CERTIFICATIOTI:Receipt of medical waste as <br /> plintirlyps Name_ w Signature <br /> s.INTERMEDIATE DI. 2 1 TRANSPORTER 2 ADDRESS. Phone <br /> l"t. Applicable Permit Numbers, <br /> ig <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or metrical waste as described above, <br /> Prkdnype Name Signature, Date <br /> 6.INTERMEDIATE NANOLSR S ITRANSPORTER 3 ADDRESS. Phone ff. <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as desmbed above <br /> P*"pe Name signature Date, <br /> 7.DISCREPANCY INDICATION <br /> [1=Alternate Facility: go Alternate Factill)r <br /> 8A.Designated Facifitir. 0 80.Alternate Faclilty; <br /> Stericycle,Inc. SterICYCle.Inc. ftricycle.Inc. <br /> Roma <br /> 35 WP%W.W 90 N.Foxboro Drtw 1551 Shathon Dirta <br /> .. - <br /> FrOfilrioCAM722 North Set Lake,UT 84064 l4offleter,CA 95023 <br /> (866)78R1422 (866)783.7422 (866)783-7422 <br /> II T=Sr 18 2016 34448-JA-313 TSIOST 83 <br /> PM TREATMENT FA&%Mf4MfV that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> reoialved the above indicatilla wastes In accordance with the requirement outlined in that authorization. <br /> PdrillnWe Name, —Signature Date <br /> Tr—aiaiRd contaffierst CU ft-tb--., <br /> 0 <br /> ORIGINAL <br />