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To: Page 40 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> . EDICAL WASTE TRACKING FORM NUMBER <br /> *O Sterrcyciv O M NCY C ACT:CHEMTREC 1.690424.93 STANDARD MANIFEST ooi-40-10-06-STD <br /> o® Nwdbgkeple. tfPkkk: � CUSTOMER NO.21132 MDFROOH872 <br /> 1,Generator's Name Address and Telephone Number <br /> AWN.-Dave Kowalczyk <br /> QUEST DIAGNOSTICS <br /> 2291 W MARCH LN BLDG F <br /> STOCXTON, CA 95207- 6652 <br /> O (209) 951-5831 12/712015 <br /> CUSTOMER NUMBER 6019888_Q02 GEtleRAToR'sREGisTRA'now# <br /> 2A.DESCRIPTION OFWASTE 28. CONTAINER TT 2C.NO.OF 20. VOLUME <br /> UN3291 Regulated Medical Waste,n.o s, Tt305 — 90 t3a1 Trib {�3 0} {5.3 t:ti Yt} CONTAINERS <br /> 6.2,PGI Cu Ft. <br /> UN3291 Regulated Medical Waste,nos, T13,19 <br /> — <br /> 6.2,PG11 Cu Ft <br /> gC UN3291,Regulated Medical Waste,a u s., <br /> O 6.2,PGU Cu FL <br /> UN3291 Regulated Medical Waste.a.os., <br /> 6.2,PGII Gu Ft. <br /> U1 UN?PatRogtdat d WRcst Wade,n.o s., — <br /> ffZ 6.2,Pat Cu Ft <br /> 5e UN3291 Regulated Mahal Waste,n.Bs., — o — a CK —(Chemo) a tiFT <br /> 62,PGII R. <br /> UN3M Regulated Redicat Waste,n os., Riosyftemg Cardboard Box Cu 'Et) <br /> 62,Phil Cu Ft <br /> UNMI Regulated Medical Waste,n oz., <br /> 6.2,PU CU Ft <br /> QU Ft <br /> S.Generator's Oertiiication:I hereby declare that the contents of this consignment are fully and accurately I T®TALS o- '3 Cu FL <br /> described above by the proper IppIng name,and are class3ied,patdtaged,mad ed and labelled(pi and <br /> are In a6 respects In proper on for transpo t acro Ing to applicable international and nation vera ntal regulations" <br /> Ptintewlrryped Name Sin —Wel <br /> 4.TRANSPORTER 1 ler Inc This is a Thro'bligh shipment <br /> W 4135 A. Swift Ave Ap Perter <br /> ® 7reano,CA 93722 au et:na egl# boa <br /> f TF2ANSP®RTE RTIFICAM=Siraturo <br /> aste as d ads •'^/•�� <br /> PrinM7ype Name Date �f b f � <br /> S.WMAMEOIATE HANDLER 2 tTRANSPORTER 2 ADDRESS: Paola#. <br /> Applicable Permit Numbers: <br /> Jill INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Prtntrrype Namo Signature Date <br /> M 6.INTERMEDIATE:HANDLER 3 t TRANSPORTER 3 ADDRESS: Phone#: <br /> ElmApplicable Penmt Nurnbers. <br /> of INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Rwelpt of medical waste as descnbed above <br /> Pri"pe lute Signature Date <br /> 7.DISCREPANCY INDICATION Trainshirmlif coiltdirlers, ou ft to: North Salt Lake,LIT <br /> Sic Dosignated Feallityr e.6.Alternate Factely: O BC,Alternate Fac inty: ®60.AkemAa FacI ty: <br /> cycle,Inc. McI,%Ia,Inc. SWrlcycie,Inc. Stettcycle,Inc. <br /> 41 ab . 90 N. otoro 1 rIn 1561 Shobn Dr*4 3140 N 7th Met <br /> a Frees ,CA 93722 AU I'pGL�1 Lelm,Ur 84064 Hollister,CA 95023 Karteas City,KS 66116 <br /> (88) 3-7422DALE ANNE RTt7been <br /> 788 (( W7 83422 i8 T83TWOST-2T6 22 <br /> • <br /> 'EC a7z 15 <br /> TREATME FiACILITY:I certify that I havoriaed by the applicable state agency W aCoept untreated medical wastes and that I have <br /> received t e above In�fmPd wastes In acch the requirement outlined in that authorization. <br /> �' G <br /> PrinllType N Signature Date <br /> ORIGINAL <br />