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To: Page 25 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> • � `__._..__ �EDICAL WASTE TRACKING FORM NUM16E>:_ <br /> o„sIN CASE OF EMERGENCY CONTACT.CHEMTREC 1-$00.424.9300 STANDARD MANIFEST oai-70•arr-STo <br /> � ericycle• <br /> • mne:unyreopieetduangfJh; Routs #• 122 CUSTOMER NO.21132 <br /> I <br /> 1.Generator's Name,Address and Telephone Number <br /> i ATTNaDave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 W NiARC:H LN SLdG P' <br /> STOCRTONr CA 95207- 6652 <br /> (20'4) g51-581-1 3114120115, <br /> CUMMER NUMBER In RA-11)(1117 GENERATORS ROGISTRA110N# <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME <br /> UN3291 Regulated Motlreai yJasto,n.as., <br /> CONTAINERS <br /> 64 PGI Cu Ft. <br /> UNS291.Regulated Medical Waste,na s., <br /> 8.2.Poll TH49 - 37 Gal Tub Hi4 4.9 OU TtI Cls Ft <br /> CC O U�9 l�Regulated Medical lhaste mos., <br /> '£H14 - 44 4al Tub B:Lo 15.9 au tt ICCu Ft <br /> Q UN3291,Regulated Medical Waste,n.c.s, <br /> cc 6,2.PGIl T921- <br /> (SSO)/TP15-(Bath)/TY15-(Chemo)20 Gal Tub(2.7GUIVT Cu Ft <br /> W6 2,Gi�Regulated A4e0ical Waste,n o s, WH31-(Bio)I -�WP31 (Paitht)/WC31-(Chemo)31 Gal Tub(4.14CUF Cu Ft, <br /> UN791 Regulated Medical Waslo,n.os., <br /> 6.2,PGI Cu Ft. <br /> UN3291 Regulated Medical Waste,n o s., <br /> 6.2,PGII Cu Ft. <br /> UN3291 Regulaled Medal Waste.mo.s., <br /> 6.2,PGII CU Ft. <br /> UUN32 1 Regulated Medical Was%n.c.s.,6. Qu Fl <br /> S.Generator's Certification:'[hereby declare Ihai the contents of this consignment are fully add rattely QTAt-$�” l ? Cu Ft <br /> Oltedi`]Wed <br /> above by the proper shipping name,and are classified,packaged,marked and labelledl�piac ed,and <br /> espects In proper condition for transport according to applicable intemationai and natio/fir rn mal regulations' � j- q <br /> Name <br /> ���`�� "-� IgrkS �'�`y �i <br /> A.TRANSPORTER 1 ADDRESS: Phone 4 hfN(trHb ^742a <br /> WStericycle, Inc. This IS a Through Shipment AppdoabloP ml s <br /> NIL 4135 V. Swift Ave Hauler Reg# 3400 <br /> w Freano,CA 93722 <br /> 0.2 TRANSPORTS RTIFICAT! ecelpt of medical waste as described a ve -3 4(f~{ <br /> / <br /> Printrrype Name Signature Date <br /> S.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone 4: <br /> N <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as descnbed above. <br /> Pdrtlrrypa Name Signature Date <br /> r <br /> a`• 6.INTERMEDIATE HANDLER 3l TRANSPORTER 3 ADDRESS. Phone It. j <br /> Applicable Permit Numbers, 1 <br /> d INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> - PmitJ7ypetVame Signature Date <br /> Ay <br /> I.DISCREPANCY INDICATION <br /> .Designated Facility: 10 08.Alternate Facility: ©80.Alternate Facility: BD.Alternate Faeln>;y: <br /> Stericycle.Inc o Stericycfe,Inc. Stericyclo,Inc. Sterlcycle,Inc, <br /> 4136'W.aw�1VVr 90 N,F*Xboro Drive 1551 shelton Drive 3140 N 7th Streettlly <br /> Freon 9722 5722 �4� North Salt Lake,UT 84054 Hollister,CA 95023 Kensae CRy,KS 6611 s <br /> ' (866)elp, 422 ��` (866)783-7422 (866)788»7422 (866)783-7422 <br /> 7'afdST22t , c SA-448-JA-36 T318ST 03 TS/OST-26 <br /> TREATMENT FACILITY.I rtify 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 to that authorization. <br /> Prtntttypo Name Signature Data <br /> Tratrsferred containers, cu It to: North Sak Lake,UT <br /> a <br /> ORIGINAL, <br />