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To: Page 19 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> ab <br /> 0 EDICAL WASTE TRACKING FORM NUMBER <br /> *a $tericy51V t CASE OF EMERGENCY CONTACT:CHEMTREC 1-800424-93* STANDARDMANIF5ST1001-il"S-STI) <br /> Route #-. 122 - 15 CUSTOMER NO.21132 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dawe Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 V MRCH L14 BLDG F <br /> STOCKTON, CA 95207- 6652 <br /> (209) 051-G83j, 4/2612016 <br /> CUSTOMER NUMBER EQVM89-002 GMER=R'S REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 28, CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,nos., CONTAINERS <br /> 6.2,PG11 TBOS - 40 Gall Tub (Rio) (5.3 au it) -1Cu Ft. <br /> UNS291 Regulated Medical Waste,nos.. <br /> 612,P(311 MB49 - 37 Gat Tub (Bio) (4.9 cu. tt) 5117 -,C.. <br /> CC UNS291 Regulated Medical Waste,Bas., <br /> 0 .6.2,Pali T914 - 44 Gal Tub(Bio) (5.9 CU tt) X Fl. <br /> UN3.2.POI291 i Regulated Medical Waste,nms4> <br /> I= T921-(gaO)/2'PI5-(Path)/TY15-(Chemo)20 Gal TubCu R(2-70UFT� <br /> uj UN3291i;to,ILO S., <br /> P611 Reoulatert Mprl[cai Wa WB31-(fto)/WP31-(Path)/WC3.1-(Chemo)3.1 Gal Tui (4..140 CU for. <br /> UNMI-Regulated MRcal—Wasje,&ojs, <br /> 6 Z Owl NE43-(Bio)/PN42-(Path)/CW43-(Chemo) Gal Tub 5.7 2U a.- <br /> UN3291,Regulated Medical Vftite,n os, <br /> 64 PGII KRB - Baa stems Cardboard Box (4.2 cu ft) Cu Fl, <br /> P UN3291 Regulated Medical Wade,n os., <br /> 6.2.PGII Cu Ft <br /> UN3291 Regulated Medical Waste,rLos., <br /> 0.2.PGli i A Qu R. <br /> Generator's Carliffeation;11 hereby declare that the contents of this consignment are fully and acc; ely <br /> above by the proper shopping name,and are dassified,packaged,marked and label d,and ING <br /> a is In Proper coriddlon for transport according to applicable International and im rnmental regulations." <br /> rIntedMiped flame/ Abcob/'O' (1 <br /> j -Slow <br /> 4.TRANSPORTER I ADDRESS: Phone 41 <br /> aSter � <br /> icycle, Inc. This is a Through shipment Applicable AmBtm <br /> 8W-7422 <br /> 4136 w. Swift Ave <br /> 1<R ]:'conn,CA 93722 Hauler Reg* 3400 <br /> TRANSPORT FITIFIC QN:Receipt of medical waste as described a <br /> J <br /> Date RC--e-S r (4 <br /> I PdrWType NameSignature <br /> S.INTERMEDIATE KAMLItP 2/TRANSPORTER 2 ADDRESS. Phone If. <br /> 0mh Applicable Permit Numbers, <br /> 1 INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Pehitillype Nam Signature —00% <br /> saw G.INTERMEDIATE HANDUR 3/TRANSPORTER 3 ADDRESS. Phone 9 <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION;Rempt of madicai waste as desenbed above. <br /> 1H <br /> P"Twe Name signaturs Date <br /> 7.DISCREPANCY INDICATION <br /> 114 — <br /> 00Slanelad Clas,Alto—mate Facility. CC­AIWMAto Facility, ❑8D.i6imata Facility. <br /> stericl6ole,Inc. StarIcycle,Inc. <br /> 4136 W. Ays <br /> Staftcle.Inc. fteAftwit Rnz so N,Foxboro Drive 1551 Sharon Odve <br /> SM <br /> 0 Fresno,CA 93, North Salt Lake,UT 84064 Hollister.CA 95023 <br /> (666}783-7422Awl 2520 W (866)783-7422 (868)783-7422 <br /> TS/OST22 SA-44844-86 MOST 83 <br /> TREATMENT FACILITY:I certifycIfitit I have been authorized by the applicable state agency to accept untreated medrcal wastes and that I have <br /> received the above Indicated wastes In accordance with the requirement outlined in that authorization. <br /> PrIIItRypo Nanta Signature Date <br /> Trandared containor.,—CU ft to <br /> ORIGINAL <br />