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To: Page 16 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> * 424 90A <br /> WASTE TRACKING FORM NUMBER <br /> 00o Stericycle! 09 <br /> AS <br /> UTeW lfftlfffY CON1jr.OHEMTREG 1-900 STANDARD MANIFEST001-10,06-STO <br /> CUSTOMER NO.21132 MDF'ROOHTVY <br /> 1.Generator's Name,Address and Telephone Number <br /> AWN.-Dave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 V MARCR LT1 BLDG r <br /> 3T0C=N, CA 95207— 6652 <br /> (209) 951-5831 5/16/2016 <br /> CMOMER NUMBER 6019888-002 GENFRAiron's REGISTRATION If <br /> IA,DESCRIPTION OFWASTS 2B. CONTAINER TYPE 2C.NO.OF 20. VOLUME <br /> LMMI Regulated Medlul Waste,nos., T305 — 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br /> 6,Z PGII Cu Ft <br /> UN3291 Regulated Medical Waste,n.o s, T349 - 37 Gal Tub (Bits) (4-9 Cu TV <br /> &Z PGII — Cu Ft <br /> M UPWM Regulated Medical Waste,n.oz, T914 — 44 Gal Tub(Bio) (5.9 Cu. tt) <br /> 0 6.2.P611 _15__U_hemo)2U Gal Tu_BT2_.7)_CUF1y 4 7 CuFL <br /> rXi Regulated Me"— os,rLFt <br /> F <br /> W UK= Regulated Medical Waste,nos., WH31—(B:Lo)/WP31.—(Path)/WC31—(Chemo)31 Gal Tul)(4-14CUIT) <br /> Z 62.PGI1 CU Ft <br /> CS <br /> LOW Regulated Medical Waste,cos', ws43—(Bio)/pu43—(Bath)/CW43—(Chemo) tial Tub(S.7cUFT) <br /> 6.2.pall CU Ft <br /> U1091 Regulated Medical Waste,nos., MB — Biosystems Cardboard Box (4.2 cu ft) <br /> 6.2.P611 Cu Ft. <br /> UMM Regulated Medici Waste,ims—, <br /> 0-0,Poll -Cu Ft <br /> UNS291 Regulated Medical Waste,n.os, <br /> 6.2,Poll —Cu EL <br /> Generalloes Gertificatlow"I h6reby declare that this contents of this consignment are fully and rarely /27 Cu Ft. <br /> bo7ve by ft proper shipong name,and are classified,paclusged,marked and labelledipi and <br /> acts In Orbper condition for transport according to applicable intsmallonal and national g ntqi lations. <br /> I <br /> 7r�IF pod <br /> I L-1 N T�A <br /> Name cue <br /> Phone <br /> cc ATMIcycle, Inc. This IS a Through Shipment <br /> 4135 v. Swift Ave Applicable Permit Numbers. <br /> Ha <br /> rL rraesno,CA 93722 ler Reg# 3400 <br /> It TRANSPORTER modicail waste as durribed '54646 <br /> PrInUType Name —Signature Date <br /> S.INTERIMOIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone <br /> Appheablie Permit Numbers. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> PrWypa Name Signature Date <br /> 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone <br /> Applicable Pormit Numbers, <br /> INTERMEDIATE HANDLER ITRANSPORTER CERTIFICATION:Receipt of awdreai waste as described above. <br /> PrhMpe Name Signature _Date <br /> 7.DISCREPANCY INDICMION <br /> 88.Alternate Facintr. Alternate FaclIllir. 8111.Alternate Facility; <br /> rlcycic;.lilt Stericycle,Inc. stedicycle,Inc. <br /> 4130 W. 90 N.Foxboro Drive 1551 Shelton Drive <br /> Fresno, *03722North Set Lake,LIT 8404 HoIllster,CA 95023 <br /> (866)783- �ro 160% (88W83-7422 (866)783-7422 <br /> TS10 3AA48-JA-36 TSIOST as <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 /> I— received the above Indicated wastes in accordance with the requirement outlined In that authorization. <br /> PriatiType Nara* Signature Date <br /> TwOorred 0on12ffiNN;—_ou ft too <br /> ORIGINAL <br />