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To: Page 26 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICAL WASTE TRACKING MRM NUMBER <br /> Stericycle* <br /> IN CASE OF EMERGENCY CONTACT,CHEMTREC 1-BM0 <br /> 424-93 STANDARD MANIFEST 001-10-06-SM <br /> Route #: 122 – 14 CUSTOMER NO,21132 MDFROOHKDT <br /> 1 Generators Name,Address and Telephone Number <br /> ATTNtDave Kowalczyk, ti <br /> QUEST DIAGNOSTICS <br /> 2291 U MARCH LN BLDG r <br /> STOCKTON, CA 95207— 6652 <br /> (209) 951-5831 3/7/2016 <br /> cuammerl Numsefi (5019888-002 0ENMATWS RE018TRATION It <br /> 2A.DESCRIPTION OF WASTE 2B. GONTAINERTYPE 2C.NO.OF 2D. VOLUME <br /> 6Q=111 Regulated Medical Waste,n os., Taos – 40 igal Tub (Bio) (,5.3 cu ft) CONTAINERS <br /> PG Qu FL <br /> U I – 37 Gal Tub (Bio) (4.9 Cutt) <br /> 6_r TB49 <br /> PGII FIRIjulailed Medical Waste,o,o,s,. Cu Ft <br /> cc UAN91 Regulated Medical Waste,no a.. TB14 – 44 Gal Tub(Bio) (5-9 Cu ft) <br /> Cu Ft <br /> 6.21 Pell 7 <br /> 617Regulated MQdlcal Waste,Po s., T321–(BIO)7TPl5---(–Path)JTY15–(Ch4amo)20 Ga3 Tub(T.7CUFT <br /> P'C,'Ii Cu Ft. <br /> aUT291,,Regulated Medical Waste,nos., WB31–tao)/WP31–(Path)1KC31–(Chemo}31 Gal TUb(4.14CUFf) <br /> Z A Cu Ft <br /> LU Regulated Medical Waste,mas.. wB43–(Bio)/Pra43–(Path)/CT943–(Chemo) Gal Tub(5.7CUFT) <br /> 605 Pill CH Ft. <br /> U I – Biosystems Cardboard Box (4.2 cu ftp <br /> 6229 <br /> PG11 Regulated Medical Waste,nax., <br /> cit <br /> 605'r."l 1 Regulated Medical Waste,no.s., Ft <br /> UNMI Regulated Medical Waste,nos., <br /> 6.2,PGII Ca Ft <br /> 3.Generator's Certification.*1 hereby declare that the contents of this consignment are fully andAccuratety Cu Ft <br /> by ft proper shipping name,and we classified,packaged,marked and tab rife(,and <br /> in spects in proper condition for transport according to applicable international and net 9 ental rogu ns'. <br /> P diTyped Nam"DA OEIA4AU 9 to - - ----- <br /> R'FiR 1 Alfflft w—Phone <br /> 'a [] This J��Through Shipgant <br /> ricycle, Inc. Applicable Permit Numbers. <br /> 4135 9. Swift Ave Haulec Regif 3400 <br /> 0 <br /> a. Fresno,CA 93722 <br /> r :Pact <br /> xn Y" <br /> P, "'T <br /> TRANSPORTS RTIFIC�4ft Iwastemadesoribed ova. <br /> -3�2-L,4G <br /> I prinvType Nam r- Smi Data <br /> 5.INTERMEDIATE HANDLER f 2/T kANSPOATER 2 ADDAMS. phone R. <br /> "HIN Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described-above <br /> Pdnmpe Name ,Signature �Date <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRES& Phone <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rooilipt of Medical waste as desonbod above <br /> PNnViype Nam ftnatura Date <br /> 7.DISCREPANCY INDICATION <br /> 11 <br /> Designated Facllftyt q .Alternate Facility. Lj BM Afferrisla Fadlity: RD.Aftemajo Faaltr. <br /> Is.Inc Stericycle.Inc. Stieticycle,Inc. Stericycle,Inc. <br /> cs 41!33W, �t ®ti 90 N.Foxboro Drive 1651 Shaton Drive 8140 N 7th Street* <br /> Freeno, r22North Set Lake,Vr 84054 Hollister,CA 95023 Kansas CkV,Ks sails <br /> P'' (86078 7422 (898)7M7422 (868)7M7422 (886)783-7422 <br /> Z <br /> TWOS= $A-448%IA-35 TSMT 83 TSIOST-26 <br /> fit <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 /> I- received the above indicated wastes in accordance with the requirement outlined in that authorization, <br /> PdnVrype Name sigrialure Date <br /> to NOrM MR LaKU,U I <br /> ORIGINAL <br />