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To: Page wnm4e 20na*o-1o13:mc14CDT 1e7767e17e7 From:Customer Care <br /> .... ...... ____�____ <br /> 0 CASE OF 9MFRGENCY CONTACT.CHEMTR -800424-93AD STANDARD MANIFOST 0011.1"O-STD, <br /> &E&CAL WASTE TRACKING IFORM NUMBER <br /> 09 'Stelricycle' EC 1 <br /> PFOR041,"Ple MdUftRjW CUSTOMER NO.21132 <br /> Route #: 122 — 15 unvRoomnN <br /> 1.Generator&Name,Address and Telephone Number <br /> ATTNOAve Kowalczyk <br /> QUEST DIAGNOSTTCS <br /> STOCKTox, cA 98207— 6652 <br /> (2ng) 12128/2015 <br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINERTYPE 2c.NO.OF 2D. VOLUME <br /> UN3291 Regulated Medical Waste,ii.os, CONTAINERS <br /> 62,FGII 40 ft) Cu Ft <br /> UN3291 Regulated Moillcal Waste.0.0.9" <br /> U1132911 RairWated Medical Waste,a o s., <br /> UN3201 Regulated Medical Wa—sten.", <br /> 62,PG11 Cu R <br /> Cu FL <br /> 3.0ifflerator's rtillication:1 hereby declare that ft conterils;of this consignment are fully and ac�curalell Cu Ft <br /> —d ad ab the proper shipping name,and are classified,packaged,marked and lab Is <br /> In all reaps a in pmps�! on for transport accord applicable international and nalronsif am regulatlorw, <br /> Print pod amemevs-, a h it- <br /> Sterioycle, Inc. Thi-S is a Through Shipment Applicable Rjnj6j—7 42 2 <br /> 4135 19. Swift Ave <br /> Hauler Peg# 3400 <br /> Presao,CA 93722 <br /> ,z TRANSPORTER CERT11MA loal waste an descri <br /> PdnVrType peceip,do, <br /> Name BE Signature Dale <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical wasts as described above. <br /> PdrWTypo Nam Signature Date <br /> 6.INTERMEDIATE HANDLER 3 J TRANSPORTER 3 ADDRESS: p1noris el. <br /> Applicable Permit Nurnbers: <br /> I[NTSV�ESIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of rintedical waste as described abov& <br /> Prinnype Nam Signature Date <br /> 0-88.Altwriatq Facility: 111C.Aftemato Facillir —8D.AIWnwte Facility. <br /> FreenoCA 93722 North Set Lalm,UIT 64M Hollister,CA !PP23 Kansas Crw,KS WiS <br /> (M)783-7422 (866)M7422 (860783-7422 <br /> DALE ANN,4E??,RTK <br /> �A%IV 1� Arf�t4l 1, <br /> -7; siewr W <br /> FE—ATMENTFACtLITY: oert thffilh been authorized by the applicable state agency to accept untreated medical wastes and that I ham <br /> 015 we "n cordance with the requirement outlined in that authorization. <br /> me <br /> Mo —Slitnature Date <br /> ORIGINAL <br />