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To: Page 32 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICALWASTETRACKING FORM NUMBER <br /> Obi 0 sterimcliv 1-800.424-9300W -0 STANDARD MMIFEST 001-10-OB-STD <br /> IN CASE OF EMERGENCY CONTACT'CHEMTREC1-800.424-9300 <br /> mx' ' Route #: 122 - 17 CUSTOMER NO.21132 MDFROOHEQI <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dwe Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 9 NUICH LN BLDG F <br /> STOCICTOW, CA 95207- 6662 <br /> (209) 951-5831 1/25/2016 <br /> CuirromEn Numava 6019888-002 GENERATOR'S REGISTRnON# <br /> 2A.DESCRIPTION OFWASTE 28. CONTAINER TYPE 2C.NO.OF W. VOLUME <br /> 60011 Regulated Medical Waste,mo s., TE05 - 40 Gal Tub (8io) (5.3 cu ft) CONTAINERS CU Ft. <br /> UNS291 Regulated MarlicitlWaste,n.u., <br /> 6.2,Pail TB49 - 37 gal Tub (Bio) (4.9 cu ft} Cu Ft. <br /> UN32I,pol91l Rd ulatsd <br /> egulated Medical WOMB,n.%s.. <br /> IITB14 - 44 gal Tub(Bio} (5-9 au ft) 7 Cu Ft. <br /> !OR6UNail <br /> 2 M.Regulated Medical Waste,mss., GCu Ft <br /> al Tub :7 <br /> ,P <br /> IM <br /> LLI UNMI iRegulated Medical Waste.ihos. <br /> Z 6.2.PSI[ Ml-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tab#4.140 Cu Ft <br /> 111 — <br /> 0 6�'2ffG'ji Itagide"""*4%r"os- wB43-(nio)/P6f43-(p4tb)/CW43-(Chemo) Gal Tub(5.7cuFT) Cu Ft <br /> UN3291,Regulated Medical Waste,ri.o.94, <br /> 6A Poll Sioelystems Cardboard Box (4.2 cu ft) Cu Ft <br /> UN3291 Regulated Medical Waste,rLms., <br /> 6.2,PQII Gu Ft. <br /> P Ft <br /> 3.Generators Cortification:1 hereby declare that the contents of this consignment are fully and accurately L170 7 Cu Ft. <br /> de bed above by the P""M41pping name,and are classified,packaged,marked and laboll", u u' nd <br /> natio <br /> a,In I respects In P c t for transport d7 applicable Internalolal and <br /> M m tat regulaffms" <br /> 1XI intedflYped Name M=ift:t:I <br /> 'CMIWORTER I ADDRESt: Phc6fe#- (866)783--7422 <br /> stericycle, Inc. This is a ThIgh Shipment Applicable Permit Numbers. <br /> cc 4135 W. Swift Ave Hauler Aegif 3400 <br /> Irreeno,CA 03722 <br /> Signature Data b t <br /> 'C TRANSPORTER ERTIFJCATIOpRoo*etol I wasto as descnb"Q� <br /> t —X— <br /> FrInforTypo Name ce5, — <br /> 5,INTERMEDIATE Dt ER 2 NSPORTER 2 ADDRESS: Phone& <br /> Applicable Permit Numbers- <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION;Receipt of medical waste as described above. <br /> Print/Typo Name Signature Date <br /> 6.INTERMEDIATE HANDLER SITRANSPORTER 3 ADDRESS: Phone 4. <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recoipt of medical waste as described above. <br /> Pri"a Name Signature —Dido <br /> 7.DISCREPANCY INDIGOON <br /> Doolignaled Fadleirp <br /> �07 OIL Alternate Facility.- 8C.AKernate Facility: SO.Ahwnsts Facility:stericycle,In Stericycle,Inc. SterIcycle,Inc. sterk-yde,Inc. <br /> 4136W.SWWV4 90 N.Foxboro Orto 1651 Shelton©flue 3140 N IM Streettrry <br /> Fresn*,CA93722 r T% North Salt Lake,Lrr o4cail Holliskr.CA 95023 Kansas CRY,KS 6611$ <br /> ,a <br /> (686)783-7422 (866)783-7422 (1368)783-7422 <br /> T810ST22 3A-"S-JA-36 TSIOST 83 TMST-20 <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 /> PnnVrype Name Signature Dole <br /> Transferred_containers,_al if to: North Sail Lake,UT <br /> C3 <br /> C <br /> ORIGINAL <br />