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To: Page 30 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> Amok <br /> --- <br /> EDICALWASTE TRACKING FORAM NUMBER <br /> tl;®® tearlicycle' IN CASE OF EMERGENCY CONTACT:CttEMTREC 1.800.424.9300 STANDARD MANIFEST 001-10•�STD <br /> °b�'°" "`'" Route #: 722 -- 14 CUSTOMERNa2t132 MDFR001iGL0 <br /> 1.Generator's Dame,Address and Telephone Number <br /> ATTN:Dave Kowalczyk � 1101111111111111 <br /> i QUEST DIAGNOSTICS <br /> 2291 W MAPJM LN BLDG r <br /> S TOCKTON, CA 95207— 6652 <br /> (209) 951-5831 2/8/2016 <br /> CttsroMEtt tvuersss6019888-002 G15NERATCRs REWMAWN# <br /> 2A.dESCRIPTION OF WASTE 28. CONTAINER TYPE 2C.NO,OF 2D. VOLUME <br /> UN32b1 RoOulaMed Medical6+Jaste,it,e.sq <br /> CONTAINERS <br /> 6.2.PAII TBOS - 40 Gal Tub (Bio) (5.3 ©u ft) Cu Ft. <br /> 62�Gii�®utatedMelgeaiVlbste,no.s., TB49 _ 37 Gal Tub (Bio) (4.9 Cu Tt) Cu Ft. <br /> CC p 62 Pi6lRegulated M�IcalWaste, ae TB14 - 44 Gal Tub(Bio) (3.9 Cu Lt) <br /> Cy Ft. <br /> 6.2 P,lill Regulated Medial Wasto,a o s„ TB21-(Rlo)/TP1S-(para()/TY1S-(Chemo)20 Gal Tub(2.70UP Ctr Ft. <br /> lu UNU91 Regulated Medical WOO,a o.s., <br /> 8.2,Ppli WS31-(Bi.o)/WB31-(Bath)/>i .I-(Chemo)31 Gal Tub(4.14CUF ) Cu Ft <br /> UN321i d Medical Waste,n o.s, <br /> atsd9- Bio gwa3-(path)/cmd3-(Chemo) Gal Tub(5.71DUFT) CU Ft <br /> 1.11110111 Regulated Medical Waste.%o s., <br /> 62.MR giogIstems cardboard Box (4.2 CA Et) Cu Ft <br /> UNS291 Regulated Medical Waste,a.o.s., <br /> 6.2.P61i Cu Ft <br /> Ctl Ft <br /> 3.Generatar's CortiNcation:°i hereby deolere that the contents of this consignment are fly and accurately TOTALS it' Cu Ft. <br /> d ed above by(the proper shipping name,and ere classified,packaged marked and label ad,and <br /> e M a respects to proper Condition ffo�r trarrisport according to applicable lntematbrtai and n22. <br /> n nlal regulations" <br /> P tedlryped Narim &1`t J++l t +`a - e <br /> A. ORTER 1 ADDRESS; Phone"- (866)783-7422 <br /> Sterloycl,e, Inc. 0 This is a Through Shipment Applicable Permit Numbers: <br /> Q 4135 W. Swift Ave hauler Rag# 3400 <br /> Fresoo,CA 53722 <br /> CC TRANSPORTER RTIFICATIO •Receipt of medical waste as dasatb <br /> Prfn Pa Name Signature Date <br /> S.INITERMEOIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone# <br /> ' Applicable Permit Numbers: <br /> t MEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical wash described above. <br /> i'rIn 1Yaa Narne Signature Gate <br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone 8 <br /> El11i Applicable Permit Numbers <br /> r[ITES MEDIATE HANDLER/TRANSPORTER CERTiFICATION:Raceipt of medical waste as dasedbed abovo. <br /> - Pry: o N. Signature Date <br /> 7.DIS REPANCY INDICATION <br /> Designated Facility; xE a 81).Aaemste FeclBlM <br /> ty: E]&C.Amate Facility 8D.Alternate Facility: <br /> 1%11 Me Rk <br /> Stedcycie.Inc. StarIcycle,Inc. Stericycfe,Inc. awriaycle,Inc. <br /> 4136 W.SMAvofi 90 N. aAoro Drive 1$61 Shelton Drive 3140 N 701 Steettfly <br /> Freeno,CA 93 Q$ 2 North Bet Latae,LIT 84054 Hoilla ter,CA SM23 Kenlses CMV,KS S6i IS <br /> pse)783-742 (BIRS)I -7422 (866)783-7422 (666)783.7422 <br /> iS/O3T22 3A-449,,W36 TS OST 83 TWOS"(-26 <br /> w <br /> TRE,TMENT FACfLITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> receZd the above IndlcaW wastes in accordance with the requirement ouUlned In that authorization. <br /> Pri Name Signature Date <br /> to Transferred containers, cu ft to: North Sat3 Lake,UT <br /> 'Ell 1-11011.111 <br /> ' O GttitAt. <br />