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To: Page 24 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICAL WASTE TRACKING FORM NUMBER <br /> Stericycle^ C STANDARD MANIFEST 001-10-09-STO <br /> CASE C -930* <br /> e W�M15y�CYCJWrACT.CHEMTRECl-800-424 <br /> kout CUSTOMER NO,21132 MDFROOM90 <br /> ,.Generator's Name,Address and Telephone Number til ill iii till I i i i li 11 i iii iii <br /> ATTN:DavL- Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 W MRM LN BLDG F <br /> STOCXTON, CA 95207- 6652 <br /> (209) 951-6831 3/21/2016 <br /> GuarromEn NumsEn 6019888-002 GENERAMMS REGISTPATION# <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UNWI,Regulated Medical Waste,n o s., 7305 - 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS62,PGII Cu Ft, <br /> UN3291 Regulated Medical Waste,no a, TB49 - 37 Gail TUb (Bio) (4.9 Cu Ft)6.2,pGli Cu Ft. <br /> CC UN3291 Regulated Medical We.0 o 6" T014 - 44 Gal Tub(Bid) (5.9 ou Tt) <br /> &2,P011 Cu Ft. <br /> UN3291 Regulated Medial WWe,rua.s., TBZI-CBXO)ITP15-(Fatb)/TY15-(Chemo)20 641 Tub(2.7CUPT) <br /> I= 6.2.poll Cu Ft. <br /> III UN3291 Regulated Medical Wage,ass., UB31-(Bio)/NP31-(Eath)/WO31-(Chemo)31 Gal TUb(4.1.4CtUWFT <br /> Z 6 2,Pall Cu Ft <br /> IJU <br /> UNS291 Regulated Medical Waste,mas., ME42-(Rio)/PW43-(Patb)/CW43-(Chemo) Gal Tub(5-7CUFT) <br /> 6.2.poll Cu Ft <br /> UN3201 - Bosysitetam; Cardboard Box (4.2 cu ft) <br /> 6.%poll Regulated Medical Waste,nos., IKRBi <br /> — Cu Ft <br /> UN3291 Regulated Medical waste,mo.s' <br /> &Z Poll Cu Ft <br /> UN3291 Regulated Medical Waste,a as, <br /> 0.2.PG11 I Cu Ft <br /> S.Generator's Gertilloution;I hereby declare that the contents of this consignment are fully and accurately Cu Ft <br /> down f the proper shipping name,and are classified,packaged,marked and Isballediplacia(ped,and <br /> arvidg=:.z.proper condIII.PnIr transport according to applicable International and national n tal regulation <br /> wbx 14uiA� 612,111(o <br /> I yped Name <br /> A-TRfflqSFORTER 1RE Phone R: (866)703-7422 <br /> r <br /> .IS: <br /> Me cycle, Inc. This is a Through SIdpncd%4t <br /> a 4135 W. Swift Ave Applicable Pe <br /> nrat Numbers; <br /> Bauler PjBg# 3400 <br /> < Freano,CA 93722 <br /> COLE a TRANSPORTWCERTIF PINY:FtecrM of medical waste as described Va. rr <br /> PrintMpe Nams t gnature Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS- Phone 6 <br /> o <br /> oil Applicable Permit Numbers <br /> Om <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical wagla,at dosmhad above <br /> PrInt/Type Name Signature Date <br /> 6.INTERMEDIATE HANDLER 3 tTRANSPORTER 3 ADDRESS: Phone P. <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as doscribOd above <br /> 9 1 <br /> f� PrIWType Name Signature —Date <br /> 7.DISOREPANCY INDiCAMON <br /> CyllA.DwIgnatedFaclutir. " 08C.ArternateFacility: 81).Almimate Facility., <br /> -tiaidcycle.Inc topSterIcYCIV.Inc. Stericycle,Inc, SlarIcycle,Inc. <br /> Y I .Foxboro DrIve 1661 Shelton DrIve 3140 N oily <br /> 4135 CAST <br /> FreenoCASIT 11 90 N <br /> (866)783-7422 NOM Sall:Lake.UT 64054 Hollister,CA 95023 Kansas CRY.Ks 6611 a <br /> (866)783-7422 (866)783-7422 (868)7W?422 <br /> UW <br /> TWST83 TSIOST-28 j 40" RAA484"S <br /> TREATMENT IFAC)UTY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and That I have <br /> rooeNed the above Indicated wastes in accordance with the requirement outlined in that authorization. <br /> PrInUTYpe Name Signature Data <br /> I ransfarre amo Nortn are-,U T <br /> ORIGINAL <br />