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To: Page 21 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> 011111191DICAL WASTE TRACKING FORM NUMBER <br /> Stericyde* MICASE OF EMERGENCY CONTACT-'CHEMTREC 1-800-424-M STANDARD MANIFEST 001-IG46-STO <br /> Route 0: 122 - 16 CUSTOMER NO.21132 MDFR001fP3N <br /> T Generator's Name,Address and Telephone Number <br /> ATTN-.Dave Kowalczyk <br /> QUEST DIAGWOSTICS <br /> 2291 0 MARCH L1 BLDG F <br /> Slrolulmw, CA 95201- 6662 (209) 961-8831 4/11/2016 <br /> CUSTOMER NUMBER 6019888-002 GENERATOR'S REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C.NO.OF 2D. VOLUME <br /> UN=l Regulated Meditel Waste,n o a.. CONTAINERS <br /> 62,PGI) T305 - 40 Gal Tub (Rio) (5-3 Cu tt) Cu FL <br /> LWMI Rellulated MedW Waste6 n,os., <br /> CZ PG11 TB49 - 37 Gal Tub (Bio) (4.9 CU tt) CU Ft. <br /> UNW.Rogull"Me*A Waste,rhos <br /> 8Z poll 7214 - 44 Gal Tub(BiO) (5-9 Cu tt) 17, Cu Ft. <br /> UNWI Regulated Meft wage,IIAS., Ts21-(310)/TP15-(Path)/TY15-(Chemo)20 Gal Ta(2.70UPT) <br /> 6.2,Poll Cu Ft <br /> VN-ml RapAted Mcdkal Waste,a a a, <br /> Z 6,2,PG11 =3.1-(Bio)/W?33.-(Path)/VC31-(Chemo)31 Gal Tub(4.14CUlIT) Cu Ft <br /> ILI <br /> ?ZWfll imailt"d Media Waste, D s., W"3-(Bio)/pw43-(Patb)/cwd3-(Chemo) Gal Tub(5.7CUFT) <br /> P(i CU Fl. <br /> L� l Replated Meditat Waste,n o s., <br /> 02,PH KPZ— - Biosystems Cardboard Box (4.2 cu ftp Cu Ft <br /> UN390i Regulated Medical Waste,n me, <br /> 62,poll Cu Ft. <br /> UN30 Regulated Med(W Waste,n 0 S, <br /> 62,PGII dM <br /> 3.Generaftirla Certification-I hareby declare that the contents of fts consignmiant are fully and accurate TOTALS ` Cu Ft <br /> above b,the props Dd,packaged,marked and Isbell I and <br /> acts to <br /> rAlprg name,and are class[tv <br /> to <br /> ,11 proppwoonSwon r t7rt ng to applicable international and natio r let regulati <br /> 'P: <br /> *.ffaSPORTER I ADORE E <br /> e 1 (866)78 7 2 <br /> S�te lcycle, <br /> Inc. E] This is a Through shipment Appliciable Permit Numbew <br /> 4135 a. swift Ave Hauler Reg# 3400 <br /> Fraano,CA 93722 <br /> 'CC a TRANSPORTCAq Receipt of medical waste as describe Ova. <br /> 9R-CERTIFI � . r <br /> I PrktrrWe Name ?1M 5—Signature Date I <br /> 5.INTERMEDIATE HAMLEFf2/TRANSPORTER 2 ADDRESS- Phone IF: <br /> APPLcable Permit Numbew. <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Reoelpt of medical waste as dembed above <br /> Pdr"pe Name I Signature— Data <br /> B.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone a. <br /> Applicable Permit Numbers, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above, <br /> Prinitrype Name Signature Dale <br /> 7.DISCREPANCY INDICATION <br /> 8A.0 a elgentod Facility; ®SIL AIW�MMS Factiltyl 4C.Altom*f*Paeflity., ❑8D.AtUkmAt*Facility: <br /> StOrIcycle,InCLIALEX06CI "' SWlicycle.Inc. SteAcycle,Inc. <br /> 4136 W.SW ft AV$ 90 N,Foxboro Drive 1661 Shelton Dftft <br /> Fresno,CA 93722 North Sat LaM,UT 84064 Hoillster,CA 96023 <br /> (866083-7422APR 11 20 (866)783-7422 (866)783-7422 <br /> ULI TS/0=2 3A-44S-JA-M TSICST as <br /> 1 <br /> 9 <br /> CC TREATMENT FACILITY,I certo that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above indicated wastes in accordance vvith the requirement outlined in that authorization. <br /> pdntmypo Nam Signature Date <br /> Trwderre d- awwriers, Lw ft to <br /> ORIGINAL <br />