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To: Page 28 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> FORM NUMBER <br /> .o®A Stencycl-ea IN CASE OF EMERGENCY CONTACT,CHENTREC 1-SM-424.931D STANDARD MANIFEST 001.10-06-STD <br /> Roth #v 122 - 17 CUSTOMER NO.21132 MDFROOHII9 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATM-Dave Kowalczyk <br /> QtIEST DIAGNOSTICS <br /> 2201 V MARCH LN BLDG IP <br /> sToanow, CA 96207- 6662 <br /> (209) 961-6831 2/22/2016 <br /> ctivromEn Numarm GMaRgroll-S RE=TitnoN# <br /> M DESCRIPTION OFWAsTg 2B. CONrAINERTYPE 2C.NO.OF 2D. VOLUME <br /> UN329CONTAINERS <br /> 6A P611,Regulated Medical Waste,nxis., T805 - 40 Sal Tub (HiO) (5.3 CU tt) Cu Ft. <br /> UN3291 Regulated Medical Waste,ii,os., <br /> 6.21 Poll TH49 - 37 Gal Tub (Sio) (4.9 Cu tt) Ou R. <br /> UPrgl Regulated MedinlWaste,R.O.S., <br /> 82 poll 2014 - 44 Ga Tub(Dio) (5.9 Ou ft) Cu Fill- <br /> UNMI.Regulated Madkil wage—,&O'S., Ts2i-iBXol/TgJS-(Vath)/TrIS-(chemo)20 Gal Tub(2.7cUrT) <br /> 62,P611 Cu R. <br /> Lu laid-Medleat W & <br /> Waste,n.o. . <br /> 'U, <br /> Z 6MAll WWII-(Bic)/WP31-(Path)/WC31-(Cheap)31 Gal Tub(4.14CWT) Cu Ft <br /> UNMRagulailed Mefficalms- 1 <br /> 16.0.0 , <br /> 62,PGIi V"3-(Sio)/PK43-(Path)/C=43-(ChemoIt Sal Tub(S-7c Ou R <br /> UN3291 Regulated Medical Waste, <br /> 6.2,PGII =9 - Biosysol tas Cardboard Box (4.2 out ft) Cu Ft. <br /> UN3291 Regulated Medical Waste,n.o.s., <br /> 642,POR Cu±L <br /> UN3291 Regulated Medical Waste,n,o.s., <br /> 64 PGI1 <br /> 3.Generator's Certilicallon:1 hereby declare that the contents of this consignment are fully and accurately TOM <br /> des dzbw BbDifo by the proper shipping name,and are classified,packaged,marked and IabreIIWffiIaP*ded'-KW 2, Fit <br /> 2 c, <br /> ar4n at 0 to in proper on for transport according to applicable internafional and Rat' in ,tai regulation <br /> P) 4 <br /> : Narrte—mil� r0a. <br /> Z�SPORTER I ADDRES&\, R10 0 (966)783-7422 <br /> stericycle, Inc. This is a Through shiPIRIent Applicable Permit Numbers: <br /> 4335 W. Swift Ave <br /> Bauler Reg# 3400 <br /> Freano,CA 93722 <br /> TRANSPORTE FICATION;, q meth a as described va <br /> 002 <br /> PrIntrrype,Name _31gnaWre Doe <br /> 6,INTEFNEDIATE HANDLER-2-7iRAN13PORTER 2 ADDRESS, Phone 0. <br /> V41R <br /> Applicable Permit Numbir$: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PdntMpe Name Signature Date <br /> 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS- Phone It. <br /> Applicable Permit Numbers' <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:ROWIpt of medical waste as described above. <br /> PrIw7lype Name Signature Date <br /> 7.DISCREPANCY 551—CATION -- <br /> 8C.Allemate Facility: So.Alternate Facility. <br /> % <br /> ftso <br /> ricycle Inc cle,Inc. ftStericdGyde.Inc. c 9.Inc. <br /> 4136W. 90 Ilmdolgro D*a 1651 ShebrIDA" 3140 KI 7th Sftdtrfy <br /> Freano.CA 113722 NO*Slit Lift,UT 04054 Hofter,CA 96023 K061119 CRY,KS 66115 <br /> (OMM-7422 (8I%)7M?422 (866)78&7422 (M)M7422 <br /> TSIOST22 3A-44ONW36 TWOST as TSIOW-26 <br /> &A <br /> uTREATMENT FA <br /> CUJTY.-I certify that have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> reoilved the above indicated wastes In accordance with the requirement outlined in that authorization <br /> PdnfMpe Name Signature Date <br /> T=Gbrmd_ I=Wnm,-D ®ate: Kwth Sal Lake,UT <br /> . 8 <br /> ORIGINAL <br /> .................... <br />