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To: Page 34 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> MEDICAL WASTE TRACKING FORM NUMBER <br /> 04 MO Steric yclee CASE OF EMERGENCY CONTACT.cHEMTREC 1800-424-9.0 STANDA111)MANIFEST 001.10-06-STO <br /> Route.#: 122 - 14 CUSTOMER NO.21132 M12ERQOH=K <br /> 1.Generator's Name,Address andTelephone Number <br /> ATTN:Dave Kowalczyk lli I Ili 111 l it l l Il i I ll ll li l l ll Ill ill l <br /> QUEST DIAGNOSTICS <br /> 2291 N MARCH L14 BLDG F <br /> 5TOc1Ci'Ow, CA 95207- 6652 (209) 951-5831 1/11/2016 <br /> CUST40ftil NUMBER 601 888-1102 GENERATOR'S REGISTRATION# <br /> 2&DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2G NO.OF 2D. VOLUME <br /> UN 291 Regulated Medical Waste,n,os, CONTAINERS <br /> 6.2 171311 TOO$ - 40 Gal Tub (Rio) (5.3 Cu ft) Cu Ft <br /> UN02911 Regulated Medical Woo,n,*,s. <br /> F2,FGII Replated Pkilloal Waste,a a 1"049 - 37 Gal Tub (Rio) (4.9 CU ft) Cu Ft <br /> (602?Nfi T014 - 44 Sal Tula(Bio) (5-9 Cu ft) Cu Ft <br /> 0 <br /> U2N%l Reffulated Waste.ri.os. TI&21-(Bto)/TeIS-(Path)/TY15-(Chemo)20 Gal Wub(2.7CUF7) <br /> U <br /> Cu Ft <br /> uj jTN----1 d MQIcaI Waste.no , <br /> Z PGItUB31-(Bio)/WP31-(Path)/WC31-(Cbemo)31 Gal Tub(4.14CUFr) CU Fl. <br /> I"!"II Repialix - <br /> N po uB43-(aio)/FK43-(Path)/CN43-(Chemo) Gal Tub(5.7CUPT) <br /> UN3291 Regulated Medical Waste,rias., <br /> 6.2.PG11 Biosystems; Cardboard Box (4.2 cu tt) 2M Ft, <br /> .0Pr <br /> 2911,Regulated Medical Wasta,n.os., <br /> 82 Cu Ft <br /> Qu Ft <br /> 3.Generator's Certification:I hereby declare that the contents of this consignment are fully and accurately TC Cu Ft. <br /> de Ibed above I the proper shipping name,and are dassdto4 packaged,marked and laballed(pl— and <br /> ------- <br /> V— <br /> roondillon for harisport according to applicable international and nolo mal regufallorts" <br /> DA t�aw WAu, 6 11. . &k I <br /> P li,2711 .2 <br /> T--fRAN&POATER I ADDRESS Phoria 9: (866)783-7422 <br /> stericycle, Inc. This is a Through Shipment Applicable Parnut Numbers; <br /> 4136 V. Swift Ave <br /> 40 Hauler Reg# 3400 <br /> 2SL <br /> Ft(A 1resno,CA 93722 <br /> ZTRANSPORT "N5ERTIFICAT *Receipt I <br /> Owl waste as descn <br /> Pdriviype No.. <br /> Signature Dole GI lJ <br /> ti.INTERMEDIATE HAND LEA!21TR61ANSPORTER2ADDRESS' Phone# <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> Pitntrrype Noma Signature —Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS, Phone 0. <br /> AWhcablo Permit Numbers: <br /> lea INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATIOM'Receipt of mordicat waste as cliascribed above <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> I noted 124clehr, so.Amer"Facility: 0 8C.Alternate Facility: El 90.Afternato Faclaltr <br /> S Is.Inc. stericycle.he, Sericycle,Inc. <br /> 4 1 1 5 cy AWTOCLAVE 90 N. OXb*M Drive 1561 Shefton Drive 3140 N 7th Street tly <br /> CIO* <br /> '* OXb <br /> 90' <br /> Z Nod" <br /> V1 <br /> O <br /> Cf� <br /> W T07 <br /> ft A <br /> U4' F sr(O.CA MW ANNS Of" Kansas Cky,KS 661 f 5 <br /> i,_ M L MZ NoM at Lake,LIT 840A H01118ter,CA 95023 <br /> Z (8 6)79S- 422 (888) 3.7,422 (866)793-7422 (868)783-7422 <br /> LU <br /> T 0 EN! SA-44 38 TO109T 83 1 73fOST-28 <br /> .A JAN I <br /> A <br /> I g . ; , authorized <br /> JZJTREATM N MILITY.I certify that I have been authorized by the applicable State agency to accept untreated medical wastes and that I have <br /> M <br /> te waste <br /> 4, ocor a With <br /> recefived a oue d <br /> /W,Ie4�Lle Poords With the requirement outlined in that authorization. <br /> Pdnvrype <br /> Dole <br /> Transferred containers, at ft to North Sak bake,LIT <br /> ORIGINAL <br />