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To: Page 15 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> MEDICAL WASTE TRACIaNG FORM NUMBER <br /> O's ON CASE OF JAERGENCY CONTACT:CHEMTREC 1,400-424-930 STANDARD MANWM(IM-10-08-13'ro <br /> Stericyclee <br /> 122 19 CUSTOMER NO,21132 MDFROOHUVO <br /> 1.Generator's Narne,Address and Telephone Number <br /> ATTN:Dave KowajCZyk I11111111111111 HIM 11111111111111 <br /> QUEST DIAGNOSTICS <br /> 2291 w muca LN BLDG r <br /> sToaKTON, CA 962177- 6682 <br /> cz��� 951-&831 5!23121715 <br /> cuirromlin NUMBER 6019888-002 GENemmws RE(3WMMN# <br /> 2A,DESCRIPTION OFWASTE 21s. CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> B' Regulated Medical Waste,ri.o a,, TBOS - 40 Gal an Tub (Bio) (5.3 ft) CONTAINERS <br /> . PNII Cu Ft <br /> UN3291 Reflublet!Medical Waste,mo.&, T049 - 37 Gal Tub (Bio) (4.9 CU It) <br /> 8.2,pall Cu Ft <br /> IZ UN3291 Regulated Medical Wage, TY314 - P gal T9 WO) (s.9 CU It) <br /> 0 62,Poll Cu Ft <br /> tawl flepwad medkaj Waste,h os., tS-(VatlT)ft7T5-tt;Mo)20 Gal TOR.Tc <br /> 0.2,FS11 Cu Ft. <br /> tu L=91 R Medical Waste—,mo s. WB31-(Bio)/WP31-(Eaw)/WC-31-(Cheno)31 Gal Tub(4.14CUET-T— <br /> Z 6.2,1`13211 CI,I Ft. <br /> Ili UN3291 Regulated Medical Waste,n as V843-(Rio)/eDF42-(Path)/CV43-(Chemo) Gal Tiub(5.70WT) <br /> 6.2,PGII Cu Ft <br /> UNMRegulated Medical Waste,a os'. MW - Biosystems cardboard Box (4.2 cu ft)6Z PGI{ Q EL <br /> UN3291 It9fulated Medical Waste,mo r.. <br /> di,Poll Cu Ft. <br /> UN= Regulated Medical Waste,mo.&, <br /> 0.21 Poll lOu Pt- <br /> re r's Cerdfication:"I hereby declare that the contents of this consignment are fully and accurate�y�TOTAU <br /> IV Cu Ft. <br /> d r above the proper ahIppInU name.and are classified,packaged,marked and labelled/plam ed,and <br /> all spects In proper condition for transport accon"'n o applicable international and national g mar�al regulabon& <br /> W6 <br /> Af ntedrryped Name ow <br /> *4;RXNSPCIRTER i A1ff'ESS;' Phone ii:—(-BF66)7 93--TUZ- <br /> cc ecicycle, Inaj This is a Through Shipment Appkatft Penh Nunterr. <br /> 4135 W. Swift Ave <br /> 3Z`tMIS110,0r1 00722 Hauler Reg# 3400 <br /> TRANSPORT <br /> RA RT E CE7IF!Aj1rRN.Receipt of medical waste as ciescir, <br /> i;;� Si..t.. Date <br /> PrIntorlyps Name Q'�- ; <br /> S.INTERMEDIATE HANDLER 2 t TRANSPORTER 2 AMJ9ESS- Phone <br /> IGO re <br /> 0 <br /> r be a <br /> 'a <br /> all a <br /> .X <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANsporiTER CERTIFICATION:Receipt of madmall waste as described above. <br /> PrhMpo Name Signature Date <br /> &INTERMEDIATE HANDLER 3/TRANSPOF(rER 3 ADDRESS: Phone 11: <br /> ic Applicable Permit Numbem <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as dWnW above <br /> Prww7ypa Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> 41A.Dosignalkid Facliltr. E]-iELARatn-ate Facility- F1 SC.Aftemate Facility: 11D.Afternarte Facifty.- <br /> rtcycle.hc. Staricycle,Inc. SUrIcycla,Inc. <br /> 4186 W.SWIR Avg�Ws 0 99 N.Foxboro D&A 1661 Sftsfton DrN* <br /> Freono,cAsWat- Noth Sol Lake,UT 84064 Hollister,CA 95023 <br /> U; (886)783-7422 (8M783-7422 (868)783-7422 <br /> M44&.W0Z TSWTW <br /> TREATMENT FACILITY:I afty thAhave been authorized by the appOcable 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 aulhonzation. <br /> FI&VType Name —SIgnalum Date <br /> eu Is TO <br /> 01RIGNU <br />