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To Page sror4o oms-0e-1o1a:0s1*CDT 18776791797 From:Customer care <br /> - <br /> E STETRACKING FORM NUMBER <br /> STANDARD MANIFEST 001-10-011-STI) <br /> Stericyclew CASE OF EMERGENCY CONTAOT.'CHEMTR19C 1-800 <br /> ft-dtnh9p6ad0&vW4k. Route #: 122 - 13 CUSTOMER NO.21132 -MT)FRQ QH&4 11 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dave Kowalczyk <br /> QUEST DIA(;TIOSTICS <br /> 2291 9 193= LN BUG F <br /> STOCKTOW, CA 95207- 6652 MOM 12/21/2015 <br /> 2A.DESCRUMON OFWA%TE 2B. CONTAINER TYPE 20.NO.OF 2D. VOLUME <br /> uRmi Regulated Medical Watt I ii,n.o.s., CONTAINERS <br /> U11291 Regulaled Medical Waste,moA, <br /> jE UN3291 Regulated Medical Waste,FLO 9, <br /> UJI <br /> 627 <br /> U143291 Regulated Medical Waste,A.0 S" <br /> U1113291 Regulated Medical Waste,I=, <br /> LLTOTALS 11CU Ft <br /> 3.Goneraloes Cot ffficallon:"I hereby declare that the contents of thiS porisignmorIt are fully and accurately Cu Ft <br /> rd ed a ova by the proper shipping nams,and are classified,packaged,marked and labelred/placardoct,Wfu <br /> eq 11 respects In Proper=WWon for transport according to applicable International and national I is <br /> Z 'ju - <br /> I ll,,ledtfted Name *L- <br /> ---aa 2tis <br /> Stericycle, Inc. This is a Through Shipment APPIrcable md Numbers: <br /> 4135 W. Swift Ave Hauler nag# 3400 <br /> Fresno,CA 93722 <br /> ac ITRANSPORTER ZEIRTIFICATION:Recffllpt of madned waste as do <br /> UJ <br /> Applicable Permit Numberw <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> P&WItype Name Signature Date <br /> ju S.INTERMEDIATE HANDLIER 3/TRANSPORTER 3 ADDRESS Phone <br /> Applicable Permit Numberr <br /> ONO <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICA71ON:R000lpt of medical waste as described above. <br /> Print/Type Name Slpature Date <br /> 7.DISCREPAN[GY INDICATION <br /> d le,Inc. Staricoa.Inc. SUrIcycle,Inc. <br /> IL 136W.SWRAMCLAVE <br /> OCL V <br /> NNE OR I <br /> resnO-CRAIMNNEORIV No Sl"It Lake,Ur 841064 HORIater,CA 95023 KaneasCity.K8 66116 <br /> 66)783-7422 (86 783-7422 (866)783-7422 (866)7M7422 <br /> DEC 2 12015, <br /> TR rT E NLITY:I certify that I hamw n authorized by the applicable state agency to accept untreated modlical wastes and that I have <br /> I— rMeoelve th ove dr t1d wa t in aocorda vvith the requirement outlined in that authorization, <br /> - <br />