Laserfiche WebLink
To: Page 23 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> &80104L WASTE TRACKINQ FORM NUMBS <br /> seciysie Rkge&CIA VMLR91MY ClItTACT:CKEMTREC 1.600-424-9300 SIT15MM"10-06-SM <br /> O® Stericycle <br /> CUSTOMER NQ 21132 <br /> 1.Generator's NatrMiMmss afnd�leleglongi lumber <br /> r <br /> ave ow CZy <br /> QUEST DIAGNOSTICS <br /> 2291 9 MARCH LN BLDG F <br /> mm=w, cA 95207- 6652 <br /> (209) 951-5831 3/28/2016 <br /> 6019888-002 <br /> Cusyrimer;NuMaea 0a4ERATowsRcaismA-noN# <br /> 2A.DESCRIPTION OF WASTE 20. CONTAINOR TYPE 2C.NO.OF 20 VOLUME <br /> UN3291 Regulated Medical Mate,no a., T111105 - 40 Gal Tub (Bi*) (5.3 Cu tt) CONTAINERS <br /> 6 2,PGII Cu Ft. <br /> 11=91,Regulated Medical waste, AF In V y - 37 Gn TO (B201 OU xt) <br /> 6.2,Poll Cu Ft. <br /> %C UN3291 Regulated Medical Wasle,nos., cu <br /> 6.2,PGIItmw e_ tin (2 7CUM Cu Ft. <br /> UN3291 Regulated medical Waste,n as., <br /> 6.2,All Cu Ft. <br /> ILI UN3291 RODULtOd Medical Waste,nos., <br /> W6.2,P811 Cu FL <br /> ur W132M Regulated Medical Waste,rtu., Gal T5515.7CIffilf! <br /> 8.2.PGII Cu K <br /> UPM91 Regulated Madicaf WM,n.o a., Niody-stents Cavdboard 37*-x- (4.2 ca ft) <br /> 6.2,pall Cu Ff. <br /> UN3291 Regulated Medical Waste,nx.L, <br /> 6.21 Poll Cu Ft <br /> 1.1113291,Regulated Medical Waste,n&L, <br /> 6.2,PGII Cm EI <br /> 3.Generator's Certification:I hereby declare that We contents of this consignment are fully and accurately TOTALS 00, Cu Fl. <br /> by the proper shipping name,and are classified,packaged,marked and'abe ad,and C"T 7 <br /> at. <br /> re sets;ire proper condillon for transport according to applicable international and n flonal r let regu[aVns' <br /> tion <br /> tu <br /> r,yd f T Ar <br /> Pdn Yped Nome �70 - . , <br /> Awftcle' Inc. 0 This :L!s i-t—rhrough shipok <br /> ILI 4335 W. Swift Ave <br /> AIMPOMOn400 <br /> rreancirCA 93722 <br /> TFIANSPORT RTIFTA scowl t Iced waste as desciri ad a <br /> Name Signature Data <br /> a.INTERMEDIATE HANDLER 21�M-F5VER 2 ADDRESS Phone,it: <br /> Mia Applicable Permit Numbm- <br /> rINTERMEDIA'rE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical Waage as described above <br /> PrInt/Type Name Signature Date <br /> 6.INTSP3MD[ATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone 41, <br /> Applicable Permit Numbers, <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrInYryps Name Signature Dale <br /> T.DISCREPANCY INDICATION <br /> 8A.DoeWnOWd F <br /> I'- Scully, 60.Alternate Facility: SCSAII.,g. 80.Alterrige Facility, III <br /> �4i 3 111C., SWWc19.Inc. <br /> 90 N.Fo*or*E)"" sliton DrIvilt <br /> " ; U4 I <br /> 1651 Sh <br /> FmanoOm- —0. Nodh Soft Lake.UT 84CM Hollister.CA 95M <br /> (ses)7M7422 (868)783-7422 (86G)ISS-7422 <br /> Tal"09M 3"48-JA-36 TWOST 83 <br /> Ire <br /> TREATMENT FACILITY:I certify 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 with the requirement outlined in that authorization. <br /> PdnVrype Name AMNONre Data <br /> C4 <br /> ORIGINAL <br />