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To: Page 42 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care <br /> EDICAL WASTE TRACKING FORM NUMBER <br /> s ie* Sterkyc(e' CASE OF EMERGENCY CONTACT:CHEMTREC sraNnaao MANIFEST 001-1e06-STD <br /> •• CUSTOMER NO.21122 <br /> 1.Generator's Name,Address and Telephone Number <br /> ATTN:Dave Kowalczyk I II 1 I Ali <br /> QUEST DIAGNOSTICS <br /> 2293 9 MhRCH LN BLDG F <br /> STO=ON, CA 95207- 6652 <br /> _ 11/2312015 <br /> enromrn NUMBER GENERATOWS REGISTRATION fI <br /> 2A.DESCRIPTION OF WASTE CONTAINER TYPE 2C.No.or 2D. VOLUME <br /> C1CONTAINERS <br /> 3PGII RegulatedMedicalWaste,n o.s., cu 'fCu Ft. <br /> UNMOa 2,P611 Regulated Medical Waste,n.os, TB4 9 - 37 Gal Tub (Bio) (4.9 cu ft) Cu R <br /> M .Pall tsd RQedca Waste,n.os TH14 - 44 Gal Tub BSA (5.9 Gu t t) -7 <br /> Cu FL <br /> Q 62 P611 Rs�datfii Waste,n.o.s. TB21-(B1o)/TP15-(path)/TY15-(chemo)20 Gal Tub(2.7CUFT Cu Ft <br /> LIr <br /> Wtit el Regulated GAedp at Waste,n o s, w631-(gio)/U1P31-(path)/KC31-(Chemo)31 Gal Title(4.14t:UF ) Cu Ft, <br /> 6'95�1 Regttfed Gtedkal Waste,nos., <br /> Waste, <br /> Chemo CG4t1 Tuft 5.7CUFR' . Cu Ft <br /> UN32W,Regulated McAcd Waste,n.os., <br /> 62,PGIiRin=4gtems4 all ftl uF. <br /> U1091,Regulated MdCd Waste,nos., <br /> 6.2,PGII Cu Ft, <br /> F <br /> 3.Genarstoes Certiflcatlon:1 hereby declare that the contents of flus consignment are fully and Accu y TOTALS® Cu Ft <br /> desId above by the proper ng name,and are classified,packaged,marked and labehadlpiacard ,and <br /> a respects In proper I n for transpori acoDrdin o applicable International and national tel Agutallons." �^ <br /> ntedited Name Ird I. S1 fur <br /> SPOt3fER 1 ADDRESS. Phone <br /> stericycle, Inc. ® g 366}7tiew. 2 <br /> This 2� d Through Shipment Apppcabie ermd umbers: <br /> p 4135 Tri. Swift Ave Hauler Reg# 3400 <br /> a 81 1L rftno,CA 93722 <br /> If TRANSPORTE TEF ATION:pw4iptof medical w e as descrl b <br /> ~ Frrnveype Nsme tgnaturo Dale ~" <br /> S.INTERMEDIATE HANDLER 2/TRANS OfiTER 2 AD—i— Phone ei: <br /> Applicabie Permit Numbers. <br /> ur <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> Printrrype N —_--_-- Signature Date_ <br /> q S.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS.: Phone g. <br /> S Applicable Permit Numbers <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:rtacelpt of medical waste as described above. <br /> s <br /> PrhtUrype Nanta Signature Dais <br /> T.DISCREPANCY INDICATION <br /> Trantferrett __ .___ containers, cit ft to' North Salt Lake,UT <br /> 1-14A.Deatgnated Facflny: IEJ ea.Alternate Facility: j}ac.Alternate Fadhty: ❑80.Alternate FacttiV <br /> "" tsrla Ee,ktc. t torfGycle. <br /> C. Stancycle,(nc. Steriaycle,Iftc. <br /> -+fie--- N.Foxboro DrWa 1551 hakan Drive 3140 N 7th Stfaettry <br /> Freen0,G LAVEth Salt Lake,UT 84054 Hollister,CA 95023 Kansas City,KS 66115 <br /> (866)VINVANNE ORTIZ6)763-7422 (t36E3)763.7422 (68;6)7(13-7422 <br /> TSSMT22 U 2?� ? . 4411-JA-36 TS/OST 88 TS/OST 26 <br /> r TR AT$f E T F��ELt' -A 900M, that�11-habeen authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> re thg'above indicated wastes inoG with the requirement outlined In that authorization. <br /> Pdn Name f - Signature Date <br /> 00 <br /> C�7y' <br /> ORIGINAL <br />