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To: Page 11 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> ww[)ICAL WASTE TRACKING FORM NUMBER STANDAP014AN UTftRM <br /> V01iffrY.CON CT:CHEMTREC 1-600424-4300 <br /> Stericycle' ft 14 bFR6 I <br /> CUSTOMER NO,21132 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTIJsDave Kbivalczyk <br /> QUICST DIAGNOSTICS <br /> 2291 11 MARCH LN BLDG F <br /> STOCKTON, CA 96207- 6652 <br /> (209) 951-6831 6120/2016 <br /> CUSTOMIER MUMMA 6019888-002 G EN E RATIO FVS R EM 57RATI ON# <br /> 2A.DF%CRIFMON OF WASTE 213. CONTAINERTYPE 2C.NO.OF 21). VOLUME <br /> UN3291 1 Regulated Medical Waste,ims, T305 - 40 Gal 111b (Bio) (5.3 cutt) CONTAINERS <br /> &Z Pal CN Ft. <br /> UN3291,Regulated Medical Waste,nms' - U (010) (419 CU tt) <br /> 6.2.FQIl Cu Ft <br /> CC UT <br /> 0 62 FLI I Radiated Medical Waste.P as, eqB-14 - 4 a (111110) (5.9 ou tt) <br /> CU Ft <br /> t=91 Raguf*d Medical Waste,n,E)S, <br /> 6.21 111311 Cu R. <br /> UJ UN3291 Regulated Medical Wage,RAS 1 0331-(315)7WP31-(Path)ING )31 001 TM-rf—,1TC—,UJ T) <br /> Z a PGR Cu Ft. <br /> amorl Regulaivid Modcal Waste.as.s-, MR43-0:14 (Chemo) Gal Tub(S.70UPT) <br /> 61 poll 0)IFW43-Olath) CH43 I R-3- Cu Ft <br /> t Regulated Medical Wasik na.s., KRA— - Biosystems cardboard Box (4.2 cu ft) <br /> 62,PSI1 Cu a <br /> UNMI Regulated Medical Waste,nas., <br /> 62,PGII Cu FL <br /> UN011,Regulated Ile�cal Waste,n as., <br /> 62.1`13111 gu Ft <br /> &Generator's Go ation., oraWrolaro that the contents of this ocansignment are fully and acc ly TOTALS lia' Cu Ft <br /> desorlbed above Z10h:plopellhhl ame,and are classified,packaged,marked and label rde d <br /> AgAlvkraspects Ira piops"=r0mown, 11 n r transport according to agpliciable,International and nation m Mail regulat <br /> Af ) - <br /> A Pdrocirryped Name ajkt,) <br /> CL';42�c -A-- ca-La— --t,I, - 'e qzz- <br /> CC 4-TR9119PORTER 1 AINVEL le, Inc. This -is-la"Th.ough S."jam-n- <br /> W k Applicable Permit.Numbers:- <br /> . W. Wift Ave Bauler Req# 3400 <br /> Fresnor,CA 93722 <br /> TRANISPORl'!R414"R of mefta I waste as des <br /> 1717 <br /> 9 Prfrin2e Name XtI6 <br /> HANDLER Signature Date <br /> 5.INTERMEDIATE NDLER 2/TRANSPORTER 2 ADDRESS Phone <br /> "I, Applicable Famad:Nuriatim: <br /> INTERMEDIATE HANDLER!TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PdnVfte Name Signature D&IB <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER a ADDASSs- Phone#: <br /> Applicable Permit Nunatam, <br /> 11 <br /> Ell 2 <br /> INTERMEDIATE HANDLER/TRANSPORTER cER-nFicAnom Recept of meftai waste as desenbed above. <br /> 4 X <br /> PdnMps Name Signature Date <br /> F 010WNCY INDICATION <br /> basignatad Facility. 88,Aftaimto Pacift: ❑8r-46mixto Factlity: �80.Afte m 8W Fad I Ity: <br /> suricycle,Inc. Sbricycle,Inc. Maticycle.Inc. <br /> 4136 ft JM A)*E OFj= 90 N.Ft Aaaro DrKt 1551 Sholon Orr" <br /> Fresno.CA 93M North$alt LWw.U7 84064 Holister.CA 95023 <br /> (866)783-7422 (866)783-7422 (868)783-7422 <br /> TSfOSTJWN 2 0 2016 3A-440-J"6 TSIOST 93 <br /> TREATMENT FACI!J&T4Y.dr-e4r1Fy that I have been authorized by the appitcable 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 /> Pliwlype Name -a —Signature Date <br /> SJ <br /> ORION& <br />