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To: Page 13 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> ---- OEDICALWASTE TRACKING FORM NUMBER <br /> B <br /> 1 U-424-000 STANDARD hIANIPEST out-10.08 9TD <br /> IN CASE OF EMERGENCY CONTACT:CHEMTREC t- <br /> BOO <br /> Route 0: 122 15 CUSTOMER NO.21132 MDFROOHVQ5 <br /> 1.Generatoes Name,Address and Telephone Number <br /> AWN:Dave Kowalczyk <br /> Q,UEST DIAGNOSTICS <br /> 2291 V MARCS LN BLDG F <br /> STOCXTOW, CA 95207- 6652 <br /> (209) 951-5031 6/6/2016 <br /> CUSTOMER NUMBER (5019888-002 GrNERAToin ReaisTPATioN N <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> 6118291.Regulated MM*11 0110.n.as.. TBO5 — 40 Sal Tub (Bio) (5.3 cu ft) CONTAINERS Cu R <br /> UN2291 Regulated Mildical t1balle,a a 9 TB49 — 37 Gal Tub (Bio) (4.9 cu 11%) <br /> 6.2,PGII Gu Ft <br /> M U0291 Reoulated Meftel Waste.a D s, TH14 — 44 G&I TUb(Bi*) (5-9 CU ft) <br /> Q6A Pali Ou Ft <br /> 1211�11quillitif MmCal Wage,n.0 S, TB21—(83:0)rT— —F15—(Path)/W15—(Chemo)20 Gal TUb(2.7=111 602 PG I Cu R. <br /> X <br /> LLI 602!2F9611i flatialded MeOcal blasts,mis — <br /> WB31 (Sio)/WP31—(Path)/WC31—(Chemo)31 Gal Tub(4.14CUIT) Cu Ft <br /> 6 FU�N' egulated <br /> 0 6,2. cel Waste,a a s, W863—(Bio)/PE443—(Path)/CK43—(Chemo) Gal Tub(5.7CUPT) Cu Ft <br /> UN3291,Regulated Medicill Waste,mms, KRB — Biosystems Cardboard Box (4.2 cu ft)6.2,Poll Cu Ft <br /> U N, <br /> N8291 oulatild M421 Wilsts,as.-, <br /> 6 �8 <br /> .2,Poll CM Ft <br /> UNS291 Regulated Me*aI vfttk fl.0's, <br /> 6.2.P614 Cu R <br /> tore Certification:1 hereby declare that the cordents of this consignment are fully and seal N TOTALS Ft. <br /> d r 'above by dme proper shtppatg nine,and are dasdfled packaged,marked and labelled/placa ,and "�""'""""'""' <br /> Applicable Permit Numbarr. <br /> 4135 19. swift ;e Rauler Reo 3400 <br /> rreeno,Ch 93722 <br /> TRANSPORTS SZEATIFIC: Reo_dpt of medical wasia,as described —ove —6 <br /> V—Qvm�—.... Date <br /> PdnVTypa Now I <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: N—OOF Phone <br /> Of Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recall of medical waste as described above. <br /> PdnV7ypo Name ,Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER$ADDRESS: Phone P <br /> Applicable Parmft Numbers: <br /> gal <br /> Ra <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of madicall waste as described above. <br /> Priniflyps Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> A.Designated Facilitin. 10 08.Alternate Facility: ac Alternate Facimr. 8D.Alternate Fadifty: <br /> SWrl 9,Inc. Ste6cycile,Inc. <br /> yCI& Inc 00 Cycl <br /> tiA' <br /> e <br /> e <br /> 'Inc' <br /> 4136 . 90 N.Foxboro DrWe 551 Shobn DrIve <br /> E Fresno,C*e'02) North Set U*%LJIT 84054 Hollitilter,CA 95023 <br /> ILI (866)783-?422 ' C�r, (886)7e3-7422 7 -7422 <br /> T�Inlv 1 (866) 83 <br /> TSIOM2 3A-440-JA-38 7WOST 83 <br /> TREATMENT FACILITY:I certify that 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 aoDordance with the requirement outlined in that authorization. <br /> Pr nVWe No= Bill Date <br /> Transferred conlatners, cu 1110 <br /> ORIGIN" <br />