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To: Page a1ur4e 20nm-0e-1z1sos14CDT 1e7767917e7 From:Customer Care <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> Stericycle' ACASE OF EMERGENCY CONTACT,CHEMTREC 1-8 STANDARD MANIPEST 001�10-0"TD <br /> Route 0: 122 – 16 CUSTOMER NO.21132 MDFROOHM4 <br /> 1.Generator's Name,Address and Telephone Number <br /> QUEST DIAGNOSTICS <br /> STOCrrON, CA 95207– 6652 <br /> (209) 961-6831 2/1/2016 <br /> 2A.DESCRIPTION OF WASTE 20. coNTAINERTYPE 20.NO.OF 20. VOLUME <br /> UN 291 CONTAINERS <br /> ,.,!P,,,Reculated Medical Waste.nAS, TB05 – 40 Gal Tub (Bio) (3.3 cu tt) Cu Fl. <br /> UN3291 Rogilfaried Medical Waste,n.o.s., TB49 – 37 Gal Tub (Bi*) (4.9 Qu ft) <br /> 6,2.FG11 Cu Ft <br /> CC UN3291 RoMd Medical Waste, T914 – 44 Gal Tub(Bio) (5.9 Cu ft) <br /> 6,27Regulated Medical Waste,n,o,&. KRB - Rios"tains Cardboard Box (4.2 out tt) <br /> pG111 — Cu Ft <br /> UN3291 Regulated Medical Waste,a o%, <br /> 62,PGI1 Cu Ft <br /> Cu Ft <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately LTC CuFL <br /> vil respects In proper condition for transport according to applicable international and national 90 ental maulatil"', <br /> rinted/Typed Name LVA. <br /> Skr <br /> Applicable Permit Numbers, <br /> CC 4136 9. Swift Ave <br /> 0 Hauler Reg# 3400 <br /> 20 Freeno,CA 93122 <br /> if M <br /> 5.1 TRANSPOFrrEeCr;RT)FICATIP"ootpt of Me"waste as dens a <br /> Sim filra <br /> I Prl"po Name Dab <br /> S.INTERMEDIATE HANDLER 2/TRAINSP126TER 2 ADDRESS: Phone 0- <br /> Applicable Permit Numb&-&, <br /> INTERMEDIATE HANDLER/TRANSPORTER currIFICATION:Receipt of medical waste as described above. <br /> Printflyps Name Signature —Dato <br /> &INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS- Phone 4: <br /> Applicable Permit Numbers- <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION,Reoelpt of medical waste as described above <br /> PrInimpa Nam Signature Data <br /> 7.DISCREPANCY INDICATION <br /> f5PA.Designated Facility: 80.Alternate Facility- SC Altemate Faelftt OD.Aftemate Facildy. <br /> TREATMENT FACILITY:I certify that I have been authorized by the applicablestale agency to accept untreated medlical Wastes and that I ham <br /> received the above Indicated wastes In accordance with the requirement Outlined in that authorization. <br /> Pilrillfte Name signature Dale <br /> I ram— ED it 10: Florth <br /> _ _ _ ~ <br />