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To: Page 18 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICAL WASTE TRACKING FORM NUMBER <br /> 0*O Stericyciv *N N CASE OF EMERGENCY CONTACT:CHEKMEC 1-800-424-93* STANDARD MANIFEST 001-10-06-SM <br /> CUSTOMER NO.21132 <br /> — CA <br /> 'Route 15 MnwannT.TR7r <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTH."Dwe KbWalczyk <br /> QUEST D:tPZN0sT3:CS <br /> 2291 W Nuwa L'N BLDG F <br /> STOCRTOW, CA 95207- 6652 <br /> (209) 9si-fiJ133 512"MA <br /> CUSTOMER NUMBER ang-nno -- GENEnmnls REGISTRAT110N# <br /> 2A.b9SCRI PTION OF WASTE 2B. COMAINER TYPE 2C.NO.OF 20. VOLUME <br /> UN3291 Regulated Medical We*,a o s., CONTAINERS <br /> 6.2.PGII - Cu Ft. <br /> UN3291 Regulated Medial Waste,n as, <br /> 6A Pali TWT 9 - 37 OWL Tub M0 (4-9 clu tt) Cu Ft <br /> X U91.Regulated Medical We*,"'S., <br /> 0 6 N322�PallTH - 44 Gal I&(BiO) 1§.2 gn t .17 jiu Ft. <br /> UN32M Regulated Medical Waste,n o s, <br /> 6.2.Poll 1821-(BXO)/TLIIS-(Path)/TY15-(Ch emo)20 Gal Tub(2.7CUF7) Cu Ff <br /> UN3291 Regulated Medial—Waste.-Los. - - <br /> Z 6.2,pall Gal Tata 4.1$ CUR <br /> to tu UN3291 Regulated Medical Waste,a—or., <br /> 62,PG11 EA3-f Rath)IcNifl-mbla=MA) 0-2=23 CU Ft <br /> UN32M <br /> a Pr <br /> ,,,Regulated Medical Waste,rio.s. rd Box gy Ft <br /> UWJM r"alated Medical Waste,n 0 a., <br /> 6.Z PGII Cu Ft <br /> Uli'Regulated Medical Wage,n,os,, <br /> 8Z Pall ou Ft <br /> 3.Generator's Codification:"!hereby declare that the contents of this consignment are fully am—ac—culftkly TOTALS Po- Cu Ft. <br /> above by the proper slipping name,and am classified,packaged,marked and labelled/placard 4 and <br /> n, respects In Proper condition for transport according to applicable internal and na am tal regulations."�ip <br /> ntecviypod Name ignatur &&gzz <br /> 4-MANNSPORTER I ADDRESS: V <br /> stecicycle, Inc. 0 This is a Through sh4ment ApphcablePWQW.:-7422 <br /> Cm x. swift Ave Battler Reg# 3400 <br /> Frwno,CA 93722 <br /> TRANSPORTER CERTIFICATION:Receipt of medical waste as desordn® bov <br /> le'711 <br /> I Prhlvrype Nam Signature Dale <br /> 5.INTERMEDIATE HANDLIVI 2/TRANSPORTER 2 ADDRESS: Moro Ji <br /> CIS <br /> I I I Applicable Pernnit Numbers. <br /> INWRMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Roompt of medical waste as described above <br /> Pdrivrype Name Signature Date <br /> 6.INTERMEDIATE HANDIER 3/TRANSPORTER 3 ADDRESS, Phone <br /> l:6 Applicable Permit Numbers: <br /> eg <br /> OZ INTERMEDIATE HANMER/TRANSPORTER CERTIFICATION:RecaV of medical waste as described above. <br /> Priniftm Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> NA.Doalifrtnted Fboulty. 04LZ 8B.Aftemete Faelft Br-Alternate Facinty: 0-46-,M�ata Fadi ter <br /> LL Sim <br /> Ida.Inc. Stier Sb%*.Inc. <br /> N. <br /> Inc. <br /> I r- 41 36 W. 02 2L16 90 N. O)Mr*Orta W5,11 an OM <br /> Fmsno.CA 937 North Sat Lake.LIT 840FA Hollister,CA 95023 <br /> 6 (806)7M7422 (8M7M7422 (866)783-7422 <br /> T810 T22 444,4--1 RA6-"B%AA48 T9/09T as <br /> >1 I <br /> TREATMENT FACILITY.I certify that I have been authorized by the applicable state agency to accept untreated ri-tedical wastes and that I have <br /> received the above indicated wastes in accordance with the requirement outlined In that authorization. <br /> PIWPJPO Name Signature Date <br /> Trier fi*ued contalnem, eu ft to <br />