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To: Page 22 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> dm .......... <br /> W -SEDICALWASTETRACY(ING FORM NUMBER <br /> aro Ster"cle- M CASE OF EMERGENCY CONTACT-CHEMTREC 1-BOD-424-9300 STANDARD MANIFEST ooi-io.o"M <br /> V Idle Route #.- 122 - 13 CLISTOMERNO.21132 MDFROO1404H <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN*.Dave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 N MARCH. LN BLDG r <br /> STOCKTON, CA 96207 6652 <br /> (209) 961-5831 4/41/2016 <br /> CusTaum NUMBER 6019888-002 GENERMASIREGISMA'nONO <br /> 2A.DESCRIPTION OPWASTE 29. CONTAINEIRTYPE 2C.NO.OF 20. VOLUME <br /> UN3291 Regulated Meckel Waste,it,"., CONTAINERS <br /> 8.2,P01i TE05 40 Gal Tub (Bio) (5.3 CU -ft) Cu Ft, <br /> UN329Regulated Medlkaj Waste,(Lo.L, <br /> O.Z PG1II TB49 37 Gal Tub (Bio) (4.9 OU ft) Cu Ft, <br /> X 6'Z PG11 UN3291 Regulated Mailkal Waste,R.Os. <br /> TD14 44 Gal Tub(Bio) (5.9 Cu ft) 1 -2. 7 Cu F! <br /> 62 , , <br /> UN3291ll Regulated Medical WasteFto.s. TB21-(B:E0)/TP15-(Path)/TY-tS-(Chemo)20 Gal Tub(2.7cuF7) <br /> cc ,Pa <br /> Cu Ft. <br /> Ull 8N3291 Regulated Medical Waste,rk,o 9, <br /> Z U,pall WB31-(Bio)/WP31-(Pat;h)/WC31-(Chem*)31 Gal Tub(4.14CUFr) Cu Ft. <br /> uj <br /> UNW1 <br /> 6.2,PGII Regulated Medical Waste,n.0.5" W943-(Bio)/FK43-(Fath)/CK42-(Chema) Gal Tub(S.?CtIFT) Ou Ft <br /> UN3291 Regulated Medical Waste,nA.S., <br /> 6.2.P011 XRB— - Biosymtems Cardboard Box (4.2 cu ft) Cu Ft. <br /> 8N3291 Regulated Medical Waste,no.&, <br /> 6.4 Pall Cu R. <br /> UN3291 RegUlailed AWna1-W—askn.as..; <br /> 6 2,PGII Ft <br /> Ind"m <br /> S. is Certification:I hereby declare that the contents of this consignment are fully a,'cue, 111 Cu Ft. <br /> 'bed Daltbly the proper shipping name,and am classified,packaged,marked and laballe4jeca, d,and <br /> rimn all resp <br /> In proper condition for transport according to applicable international and nail aural regulations. <br /> V I VPC -11 1 /160 <br /> J4W et 41(c-"v, I <br /> L <br /> Pd Ypod Nam* <br /> 4 NSPOATEA 1 ADDMS: [j This Is a Through Shipment "ho" (866)783-7422 <br /> St <br /> Pi ericycle, Inc. Applicable Pwmit Numbem <br /> 4135 V. swift Ave <br /> '49 Hauler Regi 3400 <br /> 2& Presno,CA 93722 <br /> IML e TRANSPORTS waste as dWtftd <br /> 58-QE RI I FICAT�I "01 1 of mona; <br /> FE f r44��- L 46 <br /> T1 N6�4"-� - fl(+ <br /> 1 Pr[nVlyps Name.;Z Signature Date— <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS Phone C <br /> Applicable,Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receiptof medical waste as described above. <br /> PdnvTypa Name Signature Date <br /> in S.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS' Phone 9: <br /> 1it Wit ApplicabIS POMId Numbers: <br /> Rio INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described obom <br /> PrinVPName Signature Date <br /> A* <br /> 7.DISCREPANCY INQCArON <br /> .Designated Fadifty: 0 Fadi <br /> ea.Aftem-amtelkaduty.- <br /> scA <br /> 7-\- 0 C] . gtornate, fty. Attv�mate Facility: <br /> r.rStertc;Kle.Inc. Sts Laycle,117C. 3bgricycle,Inc. <br /> N - <br /> Q. 4136W.%&ft so I .roxtlom Od" 1661 Shelton OM <br /> 4 �$ North Salt Lake,UT W54 Hollister,CA 95423 <br /> Freano,CA 9 0783-7422 (866)783-7422 <br /> T3tOST22 AQP 31,-448-JA-36 TsfOST 83 <br /> T1Rr=ATI1Ar5NT FACILITY.I certify that I'have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> I.- IreCelVed the above indicated wastes in accordance with the requirement outlined in that authorization. <br /> I lPnnVPjpe Name Signature Date <br /> Trmfemird contgrim, cu#to. <br /> ORIGINAL <br />