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To: Page 8 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> A11111h -— — Adik --- <br /> -1W-- ---- IVEDICAL WASTETRACKING FORM NUMBER <br /> 4?49 Stericycle' I%ffRFJVElffCY COWCT-CHEMTREC I-BDO'424-9300 MRF <br /> NANIFfff I G"TD <br /> 3 1 <br /> 0 CUSTOMER NO.21132 ig <br /> 1.Generator's Name,Address and Telephone Number <br /> ATM13mm Kowalczyk 11 NUNN!11111112,11111 IN I III III I <br /> Q=RT DIAGNOSTICS <br /> 2291 V br=a LV BLDG F <br /> STOCKTON, CA 95207- 6652 <br /> (209) 961-5831 7/11/2016 <br /> CUSTOMM NUMBER 6019888-002 GENWAMPM REGISTRATION <br /> 2A.DESCRIPTION OF WASTE 28. -- CONTAINERIrYPE 2C.NO.OF 2Q. VOLUME <br /> Medical Waste,no s., *41305 - 40 Gal Tub (B:Lo) (5.3 Cu -ft) CONTAINERS <br /> 6.2. 911i Regulated Cu Ft <br /> UN3291 Regulated Medical Waste,a o s., TB49 — 37 Gal TO (Bio) (4.9 CU tt) <br /> 6.2,P011 Cu Ft <br /> it UN3291 Regulated Medical Waste,rLo.&, TB14 — 44 Gal Tub( o) (5.9 CU it) <br /> 0 6.2.PGI Cu FL <br /> 2 Regulated Medical Waste,1LO.S., <br /> PC <br /> cc Cu FL <br /> Illllegulolod Medical Waste,n.", WBNI—(Bio)/WP3.t—(Pa gi)/WU31—(ChemO)31 Gal Tub 0 <br /> — .14—M <br /> CUW602!PG'11 Cu Ft. <br /> 61 <br /> 91,,Raguldiiii Medical Waste,rto.L, tads— Gal Tub(5.7=17T) <br /> 2!2 <br /> PG Cu Ft <br /> U143291 Regulated Medical Waft aos., Mw -- Bjosygtetas Cardboacd Box (4.2 au ft) <br /> 6.2.P(Id Cu R <br /> UN3291 Regulated Medical Waste,a o s, <br /> &2,P(311 Cu Ft <br /> 1,11,13291 Regulated MR9—Waste,A 0.8 <br /> 6.2,PGII cu EL <br /> 3,Getteralor's Certification:11 hereby declare that the contents of this consignment are fully and atoura TOTALS 10- 1 27 Cu Ft <br /> d above the proper shIpp'M name,and are cLassillod,packaged,marked and label[ <br /> In an spools;%proper n for transport accordl I applicable internallonal and nate ve m [at re"Wits, <br /> I <br /> ntedMood n <br /> d ao A0,M <br /> n an <br /> cc IFKANSPORTER I A fiwffiCycle, x1ita. [3 Trda :Ls a Trizough aMpment <br /> rc <br /> Applie Permit Numbens. <br /> 4135 0. Swift Ave Hauler Reg# 3400 <br /> Fresno,CA 93722 <br /> ad <br /> z TRANSPORTER Q,9 TION medical waste as described <br /> —cr A : P, &g—b,— -7-44(o <br /> a*R PdrdlYpe Nam -r_KIFICA Date <br /> 5.INTERmgbtATEHAND;LIER2 <br /> "i'TFAAii9FI(S <br /> FFFER 2 ADDRESS: Phone 41, <br /> I'im Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt or medical waste as described abms. <br /> PrInVTYpe Name ,Signature Date <br /> 6.INTRIFIMEDIATIE HANDLER 3/TRANSPOATER 3 ADDRESS: Phone 0: <br /> ra Applicable Permit Numbers: <br /> o INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medicaL waste as described above. <br /> Prinywe Name Signature Date <br /> 7.DISCREPANCY INMATKIN <br /> ['VA,0*sIgnWed Facility: C]MAlternato Facility: C]&C.Alternate Facility. 81).Alternate Facility. <br /> 'Rofilcycle Inc Starlayde,Inc. SUrIcycle.Inc. <br /> 413115 WARW OMIZ 90 N.laftoro Orlies 1661 ShQftn!give <br /> Presn*,CA 93722 Norlh 30Lsk&.UT 84054 HoUlaten CA 95023 <br /> 99 (881111))IM7422 (1386)783-7422(1386)783-7422TW2122916 M448%W38 MOST 03 <br /> TREATMENT!FACILITY:I ify that)have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> I-- reetalved the above Indicated wastes In accordance with the requirenvni outlined in that authorization, <br /> PdnVTYPe Name —Signature Date <br /> 111 Itu <br /> C14 <br /> ORIGINAL <br />