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To: Page 45 of 45 ® 2016-09-12 13:06:14 CDT 18776791797 From:Customer Care
<br /> WASE OF EMERGENCY CONTACT. CHEMTREC 1-1100424-0
<br /> Stericyce*
<br /> • p1membig"Ople,RfmubIm. Route ft 122 - 21 CUSTOMER NO.21132 NIDIT1100143132
<br /> 1.Generator's Name,Address and Telephone Number
<br /> AWN.-Dave Kowalczyk �� � � 1 r � iI �1
<br /> QUEST DIAGNOSTICS f 1111 11 11 EEII till 1 EI!11
<br /> 2291 X NUIZIR LN BLDG F
<br /> STOWMN, CA 95207- 6652
<br /> (205) 951-5831 11/2/2015
<br /> COMMER NUMMISK 6019888-002 GgNmAToRs REammnom#
<br /> 2A.DESCRIPTION OF WASTE 25. CONTAINER TYPE 2C.NO.OF 2D, �VOLUI%JE
<br /> UN3291,R%MaWd Madicsi Wasle,nos., CONTAINERS
<br /> &2.Pat TBOS - 40 Gal Tub (Bio) (5.3 cut ft) Cu Ft
<br /> 291,"ated Modical Waftao&, TB49 - 37 Gal Tub (Rio) (4.9 ou ft)
<br /> 6.2.Pal Cu Ft
<br /> JK UN3291,Regulated meftl Waft,nas, TS14 - 44 GalTub(Bio) (5.9 CU ft)
<br /> 0 6.Z Pal 12 7 Cu Pit
<br /> UN3291,Regulated Madcal Yhole,"as, TB21-(11110)ITFI-5-(kith) TY15-(dh-emo)20 Bal Tub(2:70WT)
<br /> 62,Pal Cu Ft.
<br /> Vwwl,Regulated Mekol Waftaos, UB31-(Bio)/WP31-(Pat11)/WC31-(Chomo)31 Gal Tub(4.14CUF
<br /> V,Pal Cu Ft.
<br /> LU
<br /> LINIbi,RoploW MadcolWasta,n ob,
<br /> 6 2,PC41 WB43-(Bio)/PW42-(Path)/CW43-(Chemo) Gal Tub(S.7CUPT) Cu Fl.
<br /> UN3M,RowWed Nedcal Waste.no%, MB - Biosystems Cardboard Box (4.2 au ft)U.PGII — CU FL
<br /> LINM,R&jUWW
<br /> 62.Pal Cu R
<br /> UN3291,RepilatedModem Waste,a,as.
<br /> V.Pal Cu Ft.
<br /> 3.Gone tar's Certification: 'I hereby declare that the contents of this consignment are fully and accu 10,
<br /> I Cu Ft
<br /> deftfibad raper shipping nam and are clasulfied, claiged,marked and labollediplacat! and
<br /> eIRIn a$ s�-cts In pro or condition acc-ling to applicable Intemetbital and naLLonal _xem ns-,
<br /> t!transport. ho,
<br /> re
<br /> dfte~ A I i =nab'
<br /> rTPEN-NSPORTER I ASV:IFS
<br /> erfyCle'. Inc. Tbd--g lft7a�Trough Sh�VeTkt Applicable Permit Numberr
<br /> >- 4135 V. Swift Ave
<br /> Presno,CA 93722 Baular Reg# 3400
<br /> TRANSPORTER eEINTIZATIOMpt of medical waste as desorl d
<br /> ftnlrrype t4ame- SignatureDate
<br /> 5.INTERMEDIATE HANDLER 2 1 TRANdPORTER.2 ADDRESS: \j Phone
<br /> Ng Applicable Permit Numberw.
<br /> n1lo rate! COTOTA
<br /> sj Yk
<br /> re and
<br /> INTERMEDIA YE,�H6DLER TFVkNTER CERTIFI<ATION�- -4-15'dicall Mcribed a
<br /> N
<br /> P611(lType,NameQ�Mnalu Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS-. Phone
<br /> S 1 Applicable Permit Numbers:
<br /> o INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PnnVType Name Signature Date
<br /> 7.DISCREPANCY INIDICATION 71ransferred—containers,—cu A to : North Saft Lake,uT
<br /> t. RgeCD-aidgnatad facility: 89.Alternate Facility.- E]80.Alternate Facility. El 411).—Alternate Faclitir.
<br /> JJJJ ricycle,Ina. Stericycle,Inc. Vmrlcycle,Inc. Sterlcycle,Inc.
<br /> pe W.9.*&Ave 90 N.Foxboro D" 1551 ShGbn Dfi" 3140 N 7th Streettrfy
<br /> Fre - ---- --W—
<br /> WjU-4%.A-Z-y1;e orth-.5ali Ulm,UT 84064 Hollister,CA 9SM-3 Kansas M.KS 661I S
<br /> (89)783-4422 'AU1T)CLAVI 3-7422 (886)"3-7422 (SM783-7422
<br /> DALE ANNE 01;,TIZ 1(6466)71
<br /> UJI 08 jA.1r,
<br /> TWOST 83 TMST-26
<br /> TRUATME 4T•FA 1-17APY,90;(haft leave been tuthartzed by the applicable state agency to accept usitrested inedloal Waste$and that I have
<br /> F- received 0 a Indicated wastes In accordana With the requirement outlined in that authorization.
<br /> Print/Typo Nqmo- AI& 1 Signature Date
<br /> ORIGINAL TRACVJN9 DOCUMENT
<br />
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