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To: Page 12 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICALWASTETRACKING FORM NUMBER <br /> 0* CASE OF EMERGENCY CONTACT:C14EMTREC I-aW424-93* STANDARD MANIFEST 001-10-06-STD <br /> *** Steric <br /> -Y;le* <br /> h."keft"It ARft1w Route 0: 122 - IS CUSTOMER NO.211S2 <br /> 1,Generator's Name,Address and Telephone Number <br /> AWN.,Dave Kowalczyk <br /> QUEST DIAGWSTICS <br /> 2291 2 MARM LN BLDG Ir <br /> ST N, CA 95207- 6662 <br /> _J209) 951-5831 6/-13/2016 <br /> cuirromari RMSER 601 888-002 GENERA10"REMSTRAMON# <br /> 2A.DESCRIP11ON OFWASTE 25. CONTAINERTYPS 20.NO.OF 20. VOLUME <br /> CONTAINER$ <br /> =9Regulated Medical Waste.leo s. <br /> 0.2.Po1ll T805 - 40 Gal Tub (bio) (5,3 cu tt) Cu Ft. <br /> IM329,Rogliblad Medical Wage,nox., <br /> &2*Pli1tt T949 - 37 Gal Tub (Bio) (4.9 cu tt) Ou Ft. <br /> M UN32gi Replated Medical Waste,mms. <br /> 0 6.2,Poll TB14 - 44 Gal Tub(Bio) (5.9 cu tt) Cu Ft <br /> 6Uf�Spalli 116110111811 Medical Waste,11,0*6- T82.t-(Rzo)/TPIS-(Pat h)/TY15-(Ghemo)20 Gal Tub(2.7CtW2) Cu Fl. <br /> M <br /> W UN329,Regulated Medical Waft,tia S., <br /> Z 6A Po1ll W1131-(Bio)/WP31-(Path)11031-(Chemo)31 Gal Tub(4,14CUFT) Cu R. <br /> W <br /> 0 <br /> 291 Replated Medical Waste,MOA,6.2.361 WR43-(Bio)/IRW42-(Path)/CW43-(Chemo) Gal Tub(S.7CUPT) Cu Ft. <br /> 11 16d Medical Waste,nc.s., <br /> lell iW* EM - Sicisystems Cardboard Box (4.2 cu tt) <br /> UNS291 Regulated Medical Waste,ILO.S.. <br /> a 2,PGII Oil R <br /> LIN3291 Replated Medical Waste,nw., <br /> 6-2,PGII Cu B <br /> 3.Gationitor's Certificatlowl hereby declare that the contents of this Consignment are fully and accurately GALS 10- F2 OuFt <br /> described above by the proller"pIng name,and ansdawilled,pad(aged,marked and 1"h sdlplacarded,and <br /> are In all 14 N <br /> respects in proper condition for trPA EWH ansporl acoording to applicable International and rallonnationalgovern ntal regulah s." <br /> %1 N NU- <br /> ftmdqVW Nomil S' nature ~ Data <br /> W <br /> JV <br /> CTRANSPOFtTER I ADDRESS- Phone 4 -7422 <br /> Stecicycle, Inc. This is a Thr hiptitent Applicable Permit Wnl.,t <br /> 0 4135 X. Swift Ave Rauler Reqr# 3400 <br /> IL Fresno CA 93722 <br /> IC TRANSPORTER CERTIFICATION!Receipt of medico!waste as described above. <br /> I <br /> PdAmpewame -Tf-f7f-e :RA20& —Signature Date <br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 9 ADDRESS: <br /> Applicado Permit Numbers. <br /> o <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recolpt of medical waste as described above, <br /> Pdnt%pe Name —SWnalure Date <br /> S.INTERMEDIATE HANDLER 3 1TRANS?OFrrER 3 ADDRESS: Phone P <br /> Applicable Permit Numbers <br /> INTERMEDIATE NANDLER/TRANSPORTER CERTIFICATION:Racelpt of medical waste as described above. <br /> PrimiType Name SIgnature Data <br /> 7.DISCREPANCY INDICATION <br /> OA.Deaftnated FaCINW. 8B.Alternate Facility: 10 SC.AIJAMRto Facliftr. 80.Aftemalb Facliny: <br /> suricircle.Inc. Cie. SterkV Inc. <br /> ,1 <br /> 90 <br /> 4185 W.SWR AWALA <br /> -qi"r. IftoroDrive ❑ <br /> ;I Drive <br /> Fresno,CA 93722 Noft Set Lake.UT $4054 Holl1der,CA 98023 <br /> TWO <br /> (866)7M?422 JUN 13916 ( a <br /> 868)703-722 (866)783-7422 <br /> MM , <br /> tY <br /> I i! sa TSIOST 83 <br /> TREATMENT FACILITY:I certIfy that ave 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 /> PrIntrTyrie Name ftnaturs— Data <br /> DO Transferred_containsim,_eu III to <br /> ORIGNAL <br />