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To: Page 14 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> ............................. <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> 09p <br /> 0*0 Stencycle' CASE OF EM— -—— <br /> ERGENCYC0NTACr.CHEMTREc J-sDo-424-0300 STANDARD MANIPW 001-1 O-O"TD <br /> ®s ?Mted1-VF0*Fk-kftWA- Route 0: 123 - 14 CUSTOMER NO.21132 MDFROOHVXJ <br /> I i Generator's Name,Address and Telephone Number <br /> ATTN,.Dave Kowalczyk1111111111111 IN 1111 <br /> QUEST DIAGROSTICS <br /> 2291 N MARCa LN BLDG F <br /> ST=TON, CA 96207- 6652 <br /> (209) 951-6831 5/32/2016 <br /> CusiromeR Numesn 6019898-002 GENERATOWs REoismam# <br /> 2A.DESCRIPTION oFwAsTE 28. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> UN3291,Regulated Medial Waste,me&. CONTAINERS <br /> 6.21 Pall T805 - 40 Gal Tub (Sio) (5-3 CU ft) Cu Ft <br /> UNS291 Regulated Medical waste,n4s-, <br /> 6.2,pGII TB49 - 37 Gal Tub (Bio) (4.9 cu. ft) Cu Ft. <br /> X LIN3291 Regulated Medical Wage,no.&, Cu Ft <br /> U,Pall TB14 - 44 Gal Tub(Bio) (5.9 Cu. tt) <br /> O� UN21291 Regulated Medial Wage,n o a, <br /> M 6.2.P61i T821-(BIO)/TPIS-(Path)/TYIS-(Chemo)20 Gal Tub(2.'1CUP-) Cu R. <br /> 9U UN3291 Regulated Medial Waste,nAs. <br /> Z 10,Phil wB31-(Bio)/NP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14C 1) Cu FL <br /> UJI <br /> U911i Regulated Medial Waste,n <br /> rX2N!2 <br /> PS wB43-(nio)/pw43-(Path)/CK42-(Chemo) Gal Tub(5.70U3T) .29EL <br /> I I R'llialated Medical Waste,n.o r.. <br /> 6.2,PGI1 KRB Biosystems Cardboard Box (4.2 cu ft) Cu Ft. <br /> 'NI <br /> 113291pal Regulated Medical Waste,I <br /> &2.PSI Qu Fl� <br /> UN3991 I Regulated Medial Waste,n os, <br /> (I <br /> poll Cu F. <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS)0.1 • Cu Ft. <br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placandlid,and <br /> aqjJNeII riaspma in proper condition for transport aomOng to applicable Intenm0onal and natai regulations' <br /> Al <br /> ' AldcIffterl Me= Si a PIA f- <br /> 4-7NANSPORTSER I ADDRESS. <4 7- n 10—V k� 11 <br /> Phon ii')(a 66)783- 4* <br /> Stecicyale, Inc. This is a Through shipin Aqpr:al�t Numbem <br /> 4135 X. Swift Ave <br /> 0 Hauler Reg# 3400 <br /> IRE Ca C6 Ereuno,Ch 93722 <br /> It TRANSPORTER CEEMPICATINceipt of medical waste as describe <br /> go:' <br /> /--�-3 <br /> Printirrype,Name 9M :;� (-f�; <br /> 00 —5 — Date <br /> HANDLER 9 1 TRANSPORTER 2 ADDRESS Phone INTESMEDIATF!H Phone#: <br /> Applicable Permit Numbers:INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descrilmd above <br /> Prl"pe Name Signature Date <br /> S.INTERMEDIATE HANDLER 43 1 TRANSPORTER 3 ADDRESS. Phone M, <br /> Applicable Permit Number g; <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medwall waste as described above <br /> Pdnt/Typo Name Signature Date <br /> T.DISCREPANCY INDICATION <br /> A — <br /> .13881SnAteti Facinty: 0-isi-irter n-ate Facility. 0 MAternate Facliltr. ETOD.Altemate Facility:r <br /> thryda,Inc.4ftdcyde,Inc. Starlaycle,Inc. <br /> 1S <br /> 4136 W.MR Aw 90 N.Foxboro Dm 156 t sftadn a <br /> om <br /> Foi <br /> resnCA 9372200 0, <br /> North Solt Lake.LIT 84054 Hollister.CA 95023 <br /> (866)783-7A22 %J%% <br /> icu )793-7422 (888)783-7422 <br /> TS/09T22 3A-"6,JA,36 TSMST63 <br /> TREATMENT FACILITY:I cerfify 06 been authorized by the applicable state agency to accept untreated meclfcal wastes and that I have <br /> received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br /> Pfftwrypo Name Signature Date <br /> Transferred—contalriars,—CU ft to <br /> V- <br /> 01INGRUL <br />