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To: Page 43 of 45 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care
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<br /> j R•i StE�'#C�/C'e` CASE OF EMERGENCY CONTACT, CNEMTREC 1.800.424
<br /> o" rwndtVP"*,sa rssx: Route #: 122 — 12 CUSTOMER NO.21132 MDFROOMEIN
<br /> 1.Generator's Name,Address and Telephone Number 111 III IM111111111111111111 INS11 IN IN
<br /> ArrN:Dave Kowalczyk
<br /> QUEST DIAG110STIC3
<br /> 2291 W MARCH LN BLDG F
<br /> STQG9i<T'ON, CA 95207- 6652
<br /> (209) 951-6831 11/16/2015
<br /> CUSTOMER NUMBERGENERATOR'S RepsTRAmoN#
<br /> 2A.DESCRIPTION OF WASTE 28. — CONTAINER TYPE 2C.NO.OF 20. VOLUME
<br /> UNMI,Rogdatad Medrxl Waste,no a. CONTAINERS
<br /> 6,2 pr30 T865 - 40 Bal Tub (Bra) (5.9 cu ft) Cu R.
<br /> 6,23291,Regulstsd AAa wI Waste,nos,
<br /> &a,PGII T849 - 3i.Gal. Tub (Bio) (4.9 CU ft) Cu Ft.
<br /> I% UN3291,ReptatedMedwiWaste,nes, TBl4 — 49 tial Tub(Bi0} (S.9 CUt ft}
<br /> Q 6.2,P011 1 cu Ft.
<br /> F,. UN—=I-,-RephW ModicalWaslo,nos, T,B21—(BTO)/TRIS—(pa'th)/TYIS—(Chemo)20 Gal Tuh(2.7CUPT)
<br /> 6.2,PGII Cu Ft.
<br /> 6,l23291,RoOusted Medical Waste nos, WB31-(Bio)/WP31-(Path)/WC31-(Chemo)31 Gal Tttb(4.14CUFT
<br /> W6..2,PGII Cu Ft
<br /> th 62.PGII gAet� ed
<br /> Mkxt Waste,nes, ha843—(Bio)/PW43—(path)/CW43—(Chemo) Gal Tub(5.7CUPT) Cu Ft
<br /> UN3291,Rowlated Medlcsi Waste,nms.,
<br /> Bz,PGII I KRB - Riosystems Cardboard Box (4.2 cu ft) Cu Ft
<br /> t Nam,RMUalad madcal Wada,s.as.,
<br /> 6 2,PGII Cu Ft
<br /> UN3291,Rested Memel Wasta,nas,
<br /> G 2.Pal I Cu Ft.
<br /> 3,Generator's Cortlftcation: "I hereby declare that the contends of this consignment are fully and ly TOTALS rh c Cu Ft
<br /> d above byy the proper stopping name,and are claWned,packaged,ma*ed and enadi cards and
<br /> In respects!n proper oondriton far transport accordirhg to epptir�e interna�rnal and nation tal regulations'
<br /> 1edlTyRed Name mL '" tJ" M to W v 1+wrr J„ T IT�nat' -
<br /> 4.T
<br /> 4.T PORTER 1 ADDRESS: Phone : (8 66)783-7422
<br /> ut SteciCgcle, Ines. This is a Through Shipment Applicable Permit Numbers,
<br /> 0 4135 V. Swift Ave 8suler Reg# 3404
<br /> 0 Fresno,til. 93722
<br /> TRANSPORTS RTI [CAT ecelpt of mitacel waste as de ads v .
<br /> pdnrlfype Meme Signature Date
<br /> 5.INTERMEDIATE HANDLER 21 TRANSPORTER:2 ADDRESS: Phone P
<br /> FA Applicable Permit Numbers
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recalpt of medical wads as deacnbed above,
<br /> PdnVrype Name Signature Date
<br /> no B,INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: Phone fp
<br /> Applicable Permit Numbers.
<br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Recelpt of medical waste as described above.
<br /> Pjirt/Typs Nine Swnature Cate
<br /> 7.DISCREPANCY INDICATION
<br /> Transferred Colltolne , 0111 R to: With Sats Lake,UT
<br /> &�A.Deslgnatcd Faoirtty: 88.An9rnato Faci111y tit.RltarrratB Facitlge sD,Atfemalo Faelrtty:
<br /> ca --tMrIcycle,Inc. Stericycle,I=. Stericycle.Inc. Sterltycle,Inc.
<br /> SON.Foxborn Dave 1551 Shollon Grim 3149 N 7th StreetM
<br /> Fre 2 V4 Ntith Salt Lake,LIT 84054 Hollister,CA 95023 Korlaas Cly,IGS 6611115
<br /> Z (pS� E OkTIZ (86S)753.7422 (666)783-7422 (866)7113.3-7422
<br /> TSfOST22 3A-"O-JA-3G 73/09T 63 TSIOST-26
<br /> Nov 16 zo��
<br /> REATMENT FACILITY:I codify that I ve been authorized by the applicable slate agency to accept untreated medical Wastes and that i have
<br /> cawed th�b ve ndicate wastes in rdence with the requirement outlined In that authonzation.
<br /> Signature Data
<br /> ORIGINAL„TRACKING DOCUMENT
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