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To: Page 17 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> StericMEDICAL WASTE TRACIONG FORM NUMBER <br /> ON CASE OF EMERGENCY CONTACT:CHEMTRFEC 1-0110"24-9300 STANDARD MANIFEST on-iri-ois.91D <br /> y;lee <br /> kdwvRw Route #: 122 - 13 cui-romER No.21132 MUR.001415M <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN.-Dave Kowalczyk <br /> QUEST DIA011110STICS <br /> 2291 N MARCH LN BLDG T <br /> STOCXTON, CA 95207- 6652 <br /> (209) 951-5831 5/9/2016 <br /> cumman utmou" 6019888-002 <br /> 2A.DESCRIPTION OFWASTE --- 2B. CONTAINER TYPE 215,NO.OF 20, VOIJUJAE <br /> UN3991 Regulated Medical Waste,u.s„ CONTAINERS <br /> 6.2,PGIi T805 40 Gal Tub (Rio) (5-3 C:11 <br /> N3291 Regulated Medwell Waste,sos„ Cu Ft <br /> U <br /> 6.2,PGII TB49 37 Gal Tub (Hi o) (4.9 Cu �t; Cu Ft <br /> CC UN32Regulated Medical Waste,pio.s., <br /> &P,P911i 6TB14 44 Gal Tub(Bio) (5.9 Cu ft) Cu Ff. <br /> !OR '6127P'Nli Regulated Medical Waste,Ices., TB21-(Bxo)/TF15-(Fath)/TYiS-(chemo)20 Gal Tub(2.7CUFT) Cu R. <br /> M -- <br /> LU 6123291 Regulated Medzi—Wasiklio 8,6.2,PH N931-(Joio)/WP31-(Path)/WC31-(Chemo)31 Gal Tub(4.14CMIT) <br /> WCU Ff <br /> UN3201, "Regulated MeWasik R.0 8„ <br /> 0 6.2,Poll wB63-(Bio)/PK42-(Path)/CW42-(Cheilo) Gal Tub(S.7etwT) l Cu Ft <br /> U1113291i Regulated Medical Waste,n.o-%. <br /> 6.2.FGD! KRR­ - Biosystems Cardboard Box (4.2 cu ft) Cu R <br /> 1.1118291 Regulated Modal Waste,gLo,s,. <br /> 6.2,PH CU 12 <br /> U03201 Regulated Medical Waste,acs., <br /> 6.2,Pali Cul Ft <br /> 3.Generator's Certification,11 hereby declare that the contents of this consignment are fully and ely TOTALS P-7 Cu Ft. <br /> dWrIW above by the Proper shipping narnei and am classified,packaged,ruftd and labs placard and <br /> al a ecla In Proper condition for transport according to applicable international and nalli over regulations" <br /> 41" 1 up <br /> 9slem <br /> NP odtryped Name A-1 ODA0"H�&L- 2�& <br /> 1111-W6114SPORTER 1 ADDRESS! 0 This is A Through Shipment Phone# (966)783-7422 <br /> stericycle, Inc. Applicable Permit Numbers <br /> 4136 V. swift Ave Hauler Reg# 3400 <br /> Freano,cA 93722 <br /> 0'Z TRANSPORTIC N:nece <br /> EI E Vt of nuidleal waste as deson 9 <br /> S.INTERMEDIATE HANDLER ZER 2 Phone N. <br /> I�CSignal"- ­6NameNameC, Data Priv Pq!a <br /> ANDIL 2 1 TRANSPORTER 2 ADDRESS: <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PtirWTypo Name Signature Date <br /> S.INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADOR M- S- Phone N. <br /> Applicable Permit Numbers, <br /> allINTERMEDIATE HANDIER/TRANSPORTER CERTIFICATION:Receipt of medical wastc as described above, <br /> PAnMpe Name Signature —Date <br /> 7.DISCREPANCY INDICATION <br /> 4ZOA.Designated Facinty- E]as.Afterruite Faellity: 8C.Aftrn <br /> eate Facility: So.Aftornato Facility. <br /> to in <br /> "ftrf n Colo, <br /> or ISbricycle.Inc. SWcycle,Inc. <br /> cs 4135 <br /> 80 N.Foxboro Drive1551 Shelton Drive <br /> NOM Sat Lake.UT 84054 Hoillster,CA 95023 <br /> (81%)M7422 q9 ti M68)783-7422 (8d6)783-7422 <br /> 1141 3A448-JA-36 TSMT 83 <br /> W <br /> TREATMENT FACILITY:I cerbly that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> recelved the above indicated wastes in accordance with the requirement outlined in that authorization, <br /> PdnVrype Name —Signature Date <br /> Transferred tyontatiners, cu ft toi,­ <br /> ORIGINAL <br />