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To: Page 27 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care
<br /> ------- AMIL
<br /> F-. EDICAL WASTE TRACKING FORM NUMBER
<br /> �
<br /> 010 W OM
<br /> of Sten4;y6n. IN CASE OF EMERGENCY CONTACT,CHENITREC 1.800-424-9300 STANDARD MANIFEST 001-110�06-STD
<br /> Route #: 122 - 17 CUSTOMER NO.21132 MDFRQQHaG0
<br /> 1.Gerieratar's Name,Address and Telephone Number
<br /> ATTN-.Dave Kowalczyk
<br /> QtMST DIAGNOSTICS
<br /> 2291 in MURCH LN BLDr. F
<br /> STOCRTON, CA 96207- 6662
<br /> (209) 951-5831 2/29/2016
<br /> Cuirromim Numem 18 8 8-0 0 2 GENERATOR'S REMSTRAT10114#
<br /> 2A,DESCRIPTION OF WASTE 20. CONTAINER TYPE 20.NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,rLos, CONTAINERS
<br /> 6.2.PGII T205 - 40 Gal Tub (Bio) (S-3 cu tt) Cu Ft.
<br /> UN3291,Regulated rlos,
<br /> 6.2,PGII TB49 - 37 Gal Tub (Bio) (4.9 CU ft) Cu Ft
<br /> cc UNS291 RCUUM MeAcal Waste,n.o I;,,
<br /> 0 61Z Poll T1114. - 44 Gal Tub(Bio) (5.9 cu ft) Cu Ft.
<br /> t� BUI!RGIII Regulated Medical Waste'll-0 s, T821-(6111)/TPIS-(Path)/TYI5-4ChemO)20 Gal TUb(2.70UFT) gm
<br /> It Ft
<br /> WUN3291I Regulated Medical Waft n.o s,
<br /> Z ox Pat WB31-(Bio)/WR31-(I?ath)/WC31-(Chemo)31 Gal Tub(4.140twr) Cu Fl.-
<br /> UN3291 Regulated Meftajl Waste,a e.g.,
<br /> 6.2.pall 9843-(Bio)ZPW4 3-t Path)/CV43-(C) Gal TubjSJOUPTI Cu Ft
<br /> UN3291 Regulated Medical Waste,a a s,
<br /> 6.2,P811 KIM - Bio stew Cardboard Box (4.2 cu -ft) Cu Ft
<br /> UN3291Regulated Medical Waste,Q.8.8.
<br /> &2.PGI I Cu Ft.
<br /> UN3291,Regulated Medical Waste,Po.s.,
<br /> 62,PGII 912 Cu Ft
<br /> S,Generator's C-tlflmftn.-4 hereby declare that the contents of this consignment are fully and ace-ura Cu Ft,
<br /> above by the proper sWhl ' 0.and are classified,packa ad,marked and labelleftli d
<br /> ?nam 4wdell
<br /> pests In proper con or transport III I a =a triternabonal and nation of tal regulations"
<br /> pQuezW-- -
<br /> tamped Name
<br /> k C7
<br /> 4.TRANSPORTER I ADDRESS'.w F.(8 ?83-7422
<br /> ,,jlR::hers
<br /> 7
<br /> Stet:icycle, Inc. This is a Through Shipment Applicable
<br /> IRrZ 4135 V. Swift Ave Hauler Reg# 340D
<br /> Freano,CA 93722
<br /> '"ANSPORTJ�;PER9FIC dicalwastansdaseftbod.S //
<br /> Pflitimpe NameAT
<br /> M327 -Sigirtatuire Data
<br /> 5.INTERMEDIATE-HAND14R 2 f TRANSPORTER 2 ADDRESS- Phone 8.
<br /> Applicable Permit mumbem
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of Medical waste as described above
<br /> Printirlype Nam Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone f,
<br /> Applicable Permit Numbers-
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of mecfmal waste as described above.
<br /> PrInMiae Name Signature - -- Date
<br /> 7.DISCREPANCY lN5jC—An5R
<br /> oo?
<br /> ,? Dasignetad
<br /> A1141111tyl co fo 88.Afterristo Facility. JE]BC Atterrate,Facility: 8D.Alternate Facility.
<br /> werloycle,Inc. SlWcycle,Inc, Wallcyc1e,Inc, swrlcycle,Inc.
<br /> 4130 W.SWft AW 90 N.F*xbom Drive 1661 Shelton D** WO N 7th Streetbly
<br /> LE Freeno,CA 93722 gWorth Salt Lake.UT 840% Holllcter,CA 95023 Kens as OW,Ka 66119
<br /> (866)763-7422 M
<br /> (866)77422 (868)783-7422 (896)703-7422
<br /> TSIOM2 W163A-448,W36 TS/OST*61)07 TSIOST-26
<br /> 7
<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 /> PrInVrype Narria SIgnaturo Date
<br /> 0 1
<br /> 0) Trmfemd canna ears, CU R to: North Bak Lake,UT
<br /> ca
<br /> ORIGINAL
<br />
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