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To: Page 29 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> MMICALWASTETRACKING FORM NUMBER <br /> 00 E OF EMERGENCY CONTACT:CHEMTREC' <br /> "" Stericycleo STANDARD MANIFSST 00140-06-SM <br /> Route #; 122 - 12 CUSTOMER NO.21132 MOFROOHHJE <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN-.Dave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 N MARCH LN BLDG F <br /> STOCKTON, CA 95207- 6652 (209) 961-5831 2J15/20115 <br /> C413=1111 NUMER 6019888-002 GfuiMYOR'S RECUSTRATM <br /> 2A.DESCRIPTION OF WASTE 2S. COKTAINERTYPE 20.NO.OF 2D. VOLUME <br /> UN3291 Regulated Medbl Waste,n.u., TE05 - 40 Gal Tub (Bio) (5.3 cu ft) CONTAINERS <br /> 6.2,All Cu Ft. <br /> U111329t,dated Medical Waste,rms, 21149 - 37 Gal Tub (bio} (4.9 CU ft)6.21 PGII Cu FL <br /> W. UN%i Regulated Medical Waste,0.0.5" TH14 - 44 Gal Tub(Bio) (5-9 CU, ft) <br /> 6.2 PGI I_ath)jtjj5-(chemo)20 Gal Tub(2.7culillj) 3 Cu FL <br /> UN3291 Regulated Medical Waste,ims., TI&2.t-(SXO)/TPiS- <br /> -(? <br /> (5,PH Cu Ft. <br /> UJ UN3291 -(Path)/=1-(0heM0)'3l Gal Tub(4,14CM T) <br /> 6 8.2,poll ROgkd*d Medical Waste,flu, WWI-(Rio)/WP;31 CUR <br /> CD UNS291,Reprated Medical waste,n.os., <br /> 62,Pall ws43-(sio)/l?w42-(Lath)/CW42-(Chemo) Gal Tub(5.7CUFT) Cu FL <br /> UN3291.Regulated Medical Waste,Itos., mm, - Siosymtems cardboard Box (4.2 cu ft) <br /> 62,PGII Cu FL <br /> IJN3291 Regulated Medical Wi de,ILO.S. <br /> 62,PGH Cu Ft <br /> Cu El <br /> 3.Generator's Certification.I hereby declare that the contents of this consigoment are fully and accurately TOTALS ld 3 1 (,2 Ft <br /> Aswilbed above by the proper sh ng name,and are classified,packaged,marked and laballeftk4rded,and - <br /> Wft all respOole In proper condiro.for transport according to applicable international and national g&jarrunental regulations' <br /> 44 i eap�k;Ad ate <br /> I nladMpadftme J(A'lle— . si _ <br /> 4.MMSPORTER I ADDRESS: — V Plane#: (B66)783-74ZZ <br /> Steticycle, Inc. This is a Through Shipment Applicable Permit Numbers, <br /> 4135 W. Swift Ave Hauler Reg# 3400 <br /> Freano,CA 93722 <br /> 7- TRANSPORTERSERTIFICATI t of medical waste as deso <br /> Pdnt/TM@ Nam ✓ Signature --Date <br /> 11.INTERMEDIATE HANDLEF21TR_ANSPORTER 2 ADDRESS: Phone JI: <br /> I'Ig Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION.Receipt of madicatwaste as dammed above, <br /> PrinY7Wm Nam smnawra Date <br /> G.INTERMEDIATE HANDQM 31 TRANSPORTER 3 ADDRESS: Phone 4, <br /> Applicqblo Pormit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of mod"waste as dosenbed above. <br /> PMUTYPS Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> NA.Doslonated Feel6tr. 88.Atternale Facilily. 10 8C.Alfemate FaWly. If]8D.Aftmelieftelilir. <br /> SlarkyCle Staricycle,Inc. Stericycle.Inc. MerIcycle.Inc. <br /> NEOFM! 90 N.Foxboro Ofte 1661 Shelton D*m 3140 N 7th Streettiti <br /> Fresno,CA 93722 North Scott Loake,UT 84054 H(Aleler,CA 95023 Kansas MS; W <br /> ,K15 <br /> ps)T9106783-7 f 198 15 2018 (886)783.7422 (866)783.7422 J886)78X7422 <br /> 1172 SA-448,W36 T9/08T 83 TS OST-26 <br /> lrI ag TREATMENT FACILITY-.I Cal I j Etat I have been authorized by the applicable state agency to accept untreated medical Wastes and that I have <br /> received the above indloated wastes in accordanoe with the retirement outlined In that authorization. <br /> PoInItrype Name Signature Date <br /> Transfamd containers, ca It to Naith gift Lake,UT <br /> V_ <br /> URAR51-N—AL <br />