|
0,96,411111, stericycle-
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1143410,234.0051—
<br />STANDARD MANIFEST 001 -10 -06 -STD
<br />protecting People. Reducing Risk.
<br />1 ° -� - .11
<br />-
<br />7,
<br />NNW.
<br />1. Generator's Name, Address and Telephone Number
<br />!it
<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B.
<br />CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />7'
<br />5 4 L 10 4-- 1-04�0 3
<br />Cu Ft.
<br />UN 3291, PG 11
<br />- IA-
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />Cu Ft.
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />-4
<br />Cu Ft.
<br />0
<br />UN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />V�-r,-; �
<br />Cu Ft.
<br />M
<br />UN 3291, PG 11
<br />LLI
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />Cu Ft.
<br />Z
<br />UN 3291, PG 11
<br />-Z,
<br />U.1
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />LIN 3291, PG 11
<br />Cu Ft.
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />Cu Ft.
<br />LIN 3291, PG 11
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
<br />Cu Ft.
<br />UN 3291, PG 11
<br />7,_
<br />Cu Ft.
<br />TOTALS
<br />10-
<br />3 Generator's Certification: "I hereby declare
<br />that the contents of this consignment are fully and accurately
<br />Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
<br />XPrinted/Typed Name Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Phone
<br />LU Applicabld-Permit Plumbers
<br /><0
<br />rr (n
<br />IL Z TRANSPORTER�CERTIFICATION:.Reaelpt of lriddkikl waste as described above.
<br />?j
<br />Print/Type Name 1,4 J-11-1 Signature Z L--4� Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 AI)IJHE:5ti:
<br />x W OJ
<br />izz
<br />n 01 --c INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Printrrype Name Signature
<br />Date
<br />; , 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />lul 4 M Applicable Permit Numbers:
<br />W
<br />Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />PrinttType Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />SA. Designated Facility: 8B. Alternate Facility: F-1 8C. Alternate Facility: 8D. Alternate Facility:
<br />6- K 0
<br />R
<br />7 1,�
<br />L)
<br />-7
<br />Z 23 J -
<br />Lu
<br />Lu
<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />I FAVE AT GENERATOR
<br />
|