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To: Page 41 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> WEDICAL WASTE TRACKING FORM NUMBER <br /> GoSterkvicle, Is CASE OF EMERGENCY CONTACT:CHEMTFIEC 1-600424-93JSTANDARD MANIFEST 001-10'08-STD <br /> '•' Route #: 122 - 16 CUSTOMER NO.21132 MDFROOH77L <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dave Kowalczyk <br /> QUEST' DIAGNOSTICS <br /> 2291 N MARCH LN =0 3r <br /> STocRwN, cA 95207- 6662 <br /> (209) 951-5831 11/30/2015 <br /> II <br /> CUSTOMER NUMBER 6019888-002 GENERATOR'S REGISTRATION <br /> 2A.DESCRIPTION OF WASTE 29. CONTAINER TYPE 20.NO.OF 20. VOLUME <br /> UNS291 Regulated Madiew Wage,nos., T305 - 40 Gal Tub (Bio) (5.3 au ft) CONTAINERS <br /> 6z Pall Cu Ft. <br /> UN3291,Regulated Medical Waste.%o s, TB49 - 37 Gal Tub (B p} (4.9 cu -ft) <br /> 62,Pal Cu Ft, <br /> M UN3291 Regulated Medical Waste,na.&, TB14 - 44 Gal Tub{Bio} (5.9 cu ft) <br /> 62,PGII Cu Ft. <br /> UN3291 Regulated Medical Waste,Ras, <br /> IIA Poll CU Ft <br /> U1 "" Regulated Med Waste,nox, gal Tub(4.14CURT— <br /> Z &Z poll cu Ft. <br /> 1.11132P96111 RW1010d Medical Waste,n.os., Ws43-(Bio)/PW43-(Path)/cw43-(chemo) Gal Tub(5.7cuFT) <br /> 62, Cu Ft <br /> UN3291 Regulated Modest Waste,nos., KRB - Biosystems Cardboard Box (4.2 cu ft) <br /> 62,PGII Cu Ft. <br /> UNM'Regulated Medical Waste.nas., <br /> 6Z PG1I Cu FL <br /> Cu Ft <br /> 0 <br /> 3. <br /> Of, floation:11 hereby declare that the contents of this consignment are fully and aocurately TOTAI <br /> stator's <br /> above proper shipping name,and are classified,packaged,marked and labellld�p gand ��5 5Cu R. <br /> hi r cts to proper condition for transport according to app(leatile International and naftorudsLomwir I reguf tfons,' <br /> V <br /> d Name <br /> '4,MWSPORTER i ERESf <br /> Stet cycler Inc. This is a Through Shipment <br /> ' <br /> 4135 R. Swift Ave AppIrelPs"it Numbers: <br /> u ev Reg# 340C <br /> Fresno,,CA 93722 <br /> ME(4 <br /> a.� TRANSPORTER CERTIFICATION:,Recelpt of mesal waste as do$ <br /> =I Pft%pQ Name C al Ke —Signature Date 92-� <br /> S.INTERMEDIATE HANDLER 2 ITRANSPORMA 2 ADDRESS Phone ff <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above <br /> PrInt(Type Nam Signature Date <br /> S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS; Phone 9. <br /> Applicable Permit Numbers, <br /> H INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION;Receipt of moclical waste as described above <br /> Pr)nVrype Name Signature Date <br /> 7.DISCREPANCY INDICATION Transferred containers,_cu ft to : North S-A Lake,UT <br /> ROA.Dus(girtat"RecW. 0$0.Alternate FW1111r. 8G.Aftemate Faculty. !C]611)Aftemiate Faciffir. <br /> tis- 01 --&erIcyQIe,Inc. stedcYCfe,Inc. Staricycle,Inc. Staftycle,Inc. <br /> :Z3 H, 413 oro DrW M1 Shelton Me 3140 N 781 Streattly <br /> ff Fres o.CA937224UT0CLA%E NorthLake, 84M Hohlater,CA 95023 Kansan City,KS 66115 <br /> F a it I <br /> (896 M7429)AL5 ANNE 0 RT12M)70 -7422 (8 783.7422 (860783-7422 <br /> �13 1 <br /> ' ea- 66 <br /> TS[ST22 -36 TWOST 83 TWST-26 <br /> NOV 3 0 20 <br /> "JUTY.I certify <br /> rt,that <br /> I ha"b-..n utl <br /> PM EATM CIILITY;I certify that I havWd'b�Feen uthortzed by the applicable state agency to accept untreated medical wastes and that I have <br /> TR A <br /> received I ova I d I i requirement outlined in that authorization. <br /> n accordanc4 with the <br /> PrifluTypis N 4� Signature Dais <br /> ORIGINAL <br /> .................. <br />