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To: Page 35 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> MEDICAL.WASTE TRACKING FORM NUMBER <br /> a.� ster•Ic cie- AS@ OF 6 CY COW4CT:CHEMTREC11-110131424-93011111s' STAWARD 4AAN,l6F ST 001-10-0ESTD <br /> •• n.c.m.ar..* wa: tics 1c"Z 7 4 CUSTOMER NO.21132 <br /> �E''Rtt uL <br /> i.Generator's Name,Address and Telephone Number HIM II <br /> ATTH.Dave Kowalczyk <br /> 111111111111 <br /> QU.BST DIAGNOSTICS <br /> 22911 w MARCH LN BLDG 8' <br /> nocKf'ONr CA 98207-- 6652 <br /> (209) 951-5831 114/2016 <br /> CUSTOMER NUMBEq 6019888-002 GENERATORS REWSTRAMN N <br /> 2A.DESCRIPTION OFWASTE 28. CONTAINER TYPE 2C.NO,OF 20. VOLUME <br /> UNMI Regulated Medal Waste,n.o.s.. TBOS — 40 gal Tub (SiO) (5-3 cu #t� CONTAINERS <br /> 8.2,PGti Cu Ft <br /> 8.22,,PGii Reitil d Me Waste,n o.s., <br /> Cu Ft. <br /> 0C t91 "allard Madal Waste,n as, — ° <br /> Y QU 114 <br /> O 6.2,1`611 Cu Ft <br /> `� 82P&tl Rezttahld Medkal Waste,n.o s., Cu <br /> tit VaP 1 Rept�led Medical Waste,n a.&, — <br /> � 6.2,PGii _ Cu Ft <br /> Bi�PGIi Re9tiktad Medial Waste,mos., — Sia — Pa etas a <br /> F <br /> O N229')Ragrrlakil Med of Waste,n as.. _ osys ems G u Cu Ft <br /> UN3291ReWJ Md Medical Waste,nos., <br /> 6.2.P1311-tie Ft <br /> Cu Ft <br /> 3.Generator%Cortillcatt by declare that the contents of this consignment are fully and accurate TOTALS' <br /> fabove by tits r lipping name,and are classified,packaged,marked and labellecilpl and <br /> leapacts Inpro c dMon for transport acoordtn applicable international and nalion govern ntai regulations."tedtfYped Nam tar <br /> cc 4.TRANSPORTER 1 Atm CYC yD r Iris e D 9.bJ st is a Ttit tagh Sttipatesit Ptf&e M <br /> 4135 N. Swift Agra tel` �t l 3904 <br /> p E>renno,CA 9:3722 <br /> a� TRANShORTER C FI ATI® Ipt of 1 waste asa <br /> cue <br /> F(41 Fypa Name Signature Dago <br /> S.INTERMEDIATE HAftIER 21 TRANSPORTER 2 ADDRESS. Phone;Y; <br /> Uj <br /> O' Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFLOA11ON:Receipt of medical waste as described above. <br /> PrhW ype Name Signature Date <br /> e, 6.INTERMEDIATE HANDLER 3 f TRANSPORTER S ADDRESS: Phone A. <br /> S Applicable Permit Numbers; <br /> ®11 <br /> INTERMEDIATE HANDLER 1TRANSPOFrrER CERTIFICATION:Recelpt of medroal waste as described above. <br /> PrlrWrypie Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> A.Designated FaelJity: aB.Alternate Facility: ®BC Alternate Facility. ❑8D Alternate Facility: <br /> Stefle 9,InG. Stericycle,In. ftrlwde,Inc. Steticycle,Inc. <br /> U LATAII&T <br /> WAR Aum 90 N.Foxboro Drh+e 1651 Stlobn DrNe 3140 N nth Streettrfy <br /> ano,CA (,AVE P Soft take,UI' 84M Hotlater,CA 96023 K uses Cts,IS 66115 <br /> )' 'a ANNE ORTIZ 66)763-7422 (SM783-7422 (666)763-7422 <br /> OST22 8-.]MSS TSIOST 83 TSIOST 26 <br /> JAN 042018 <br /> TR FACILITY:I certify that I h been authorized by the applicable state agency to accept untreated medical wastes and that L have <br /> ret; ea indicated tee in aoc.1dance with the requirement outlined in that authorization. <br /> Prft 03210 SUnature Data <br /> G? <br /> ORIGINAL <br />