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To: Page 38 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> WASTE TRACKING FORM NUMBER <br /> 4*00 SitericyC le° CASE OF EMERGENCY CONTACT:CH>3 MTREC 1-600-124.9900 STANDARD MANIFEST ODl-to-MSTD <br /> Ptolcpap Paople.AdAxIs,�Abt: cusTomeR NO.21132 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Da%-- Kowalczyk <br /> QUEST DIAGWOSTTCS <br /> 2291 fid MATtCJ:i six BLDG F <br /> STOCKTON, CA 95207- 6652 <br /> (9091 osi-sam <br /> Cusrromm NUMBERGENERATOR`S RIMI.STRATION# <br /> 2A.DESCRIPTION OF WASTE 2s• _ CONTAINERTYPE 2C,NO.OF 20. VOLUME E <br /> 6 �EI Regulated Medteal4Yasts,n.o.s„ - CONTAINERS <br /> Cu Ft I <br /> UNS291 Regulated Medbl Waste,a.o.s, <br /> TB t Cu Ft. <br /> (,1C UN2291 Regulated Medical Waste,a e S., a 5.9 cu it) Cu Ft <br /> dUNS291 Regulated MEdical Waste,n o.s., <br /> 6.2.PCsti TB21-(5xO)/TP15-(Path)/Tx15-(Chemo)20 Gal Tub(2.7cUFT) Cu FL <br /> LU UNS291 Regulated Me2cat Waste,mo-%, <br /> ZZ 6.2,PGII WB31-(Bio)/WP31-(Fath)/WC31-(Cliemo)31 sal Tub(4.14CUPTJ Cap Ft. <br /> Lu <br /> CUNN33291.Regulated Medli at Waste.mos,. <br /> t+iB43- Sio PW43- Path CW43- Chemo Gal Tub 5.7CUFT Cu Pt <br /> UN8291 Regulated Medical Waste,mos., <br /> 6.2,PGIi KRB - Riogystams Cardboard Box 4.2 cu ft Cu FL <br /> uN3291 Regulated Magical Ylasts,n as„ <br /> 6.2.PGiI Ou Ft. <br /> Cu Ft <br /> S.ftneratoea Certkficatton:'I hereby declare that the contents of ft consignment are fully and aawratel TOTALS Cu Ft. <br /> P,X'Pri <br /> e by the p ng name,and are classified,packaged,marked andcts h pron for•ttarmport acconbng applic�e international and national r e Nigu�tiane <br /> itped Nara gnatuER 1 ADDRESS: Phone 4 (q �3wStericycle, Inc. This is a Through shipment Applicable Pe. urr�perarc ?422 <br /> A135 19. swift Ave <br /> a R naulcr Reg# 34<00 <br /> Freanci,CA 93722 <br /> a TRANSPORT CE JCA• .Remipt of medical waste as dose d a <br /> Pdnt/rype Name(_ Signature Date <br /> S.tNTERMEDIATE NDLER 2/TRANSPORTER 2 ADDRESS: Phone kP. <br /> Applicable Penna Numbers <br /> Hai <br /> .19 INTERMEDIATE HANDLER/TRANSPORTER CER71FICATION:Receipt of mgwal waste as described above. <br /> r- Print/Type Name Signature Date <br /> mz 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS. <br /> Phone It, <br /> Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recut of medical waste as described above <br /> � Pdnt!lypa Nara Signature. � Date <br /> 7.DISCREPANCY INDICATION <br /> Transferred containers,-_W_____,._Icu>t to: Norlh Salt Lake,UT <br /> •r• .DoWil nated Facility: 88.Alternate Facility: Q 11I.Aaernata Facility: eD.Altemate Facility: <br /> UStena le.Inc. Stade Inc. ;S^ffiricycie Inc. Steticyc�,Inc. <br /> u'Qt. CLAVEINN <br /> F*Aoro Drive 1$61 Shobn Drive 3140 N 7th Streettrfy <br /> h MEN Salt Lake,LIT 84VA HolOster,C,A 95023 Kansas City,KS 66116 <br /> 8B8)78NE ORTI83-7422 +(aea)7OS-7422 (866)783-7422 <br /> ST22 8-.L4 36 ;TS/OST 83 <br /> TS/OST-26 <br /> W DEC 14 2015 <br /> TR M FACitITY:I certify that n authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> ravel th ova indicated wastes Ice with the requirement outliner(in that authorization. <br /> PdnYl 3e Name 3innature Date <br /> � t <br /> i <br /> ORIGINAL <br />