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<br />Notecting Popple. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 11800--23" 6'5-1 STANDARD MANIFEST 001 -10 -06 -STD
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<br />1. Generator's Name, Address and Teleph—on
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<br />Number `I iia
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<br />CUSTOMER NUMBER Oji GENERATOR'S REGISTRATION #
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<br />Signature
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />Phone ,#,,
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<br />CONTAINERS
<br />Applicable Permit Numbers:
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,
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<br />Date 43
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately �ately iy TOTALS 0- Cu F
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<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!
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<br />7. DISCREPANCY INDICATION
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<br />. A n/ BC: Alternate Facility: 8D. Alternate Facility:
<br />>. E18A. Designated Facility: 0 8B. Alternate Facility:
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<br />Ifl;TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />CC received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />CSPrintfType Name Signature Date
<br />LEAVE AT GENERATOR
<br />APrinted/Typed Name
<br />Signature
<br />Date
<br />Applicable Permit Numbers:
<br />4. TRANSPORTER I ADDRESS:
<br />Phone ,#,,
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<br />Applicable Permit Numbers:
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<br />Print/Type Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />TRANSPORTER -CERTIFICATION: jAec`6ipt 6imidical waste as described above.
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicalwaste as described above
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<br />1 Print/Txina Name !4" Signature
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<br />7. DISCREPANCY INDICATION
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<br />. A n/ BC: Alternate Facility: 8D. Alternate Facility:
<br />>. E18A. Designated Facility: 0 8B. Alternate Facility:
<br />LL. s
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<br />Ifl;TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />CC received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />CSPrintfType Name Signature Date
<br />LEAVE AT GENERATOR
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />CM UJ
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medicalwaste as described above
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />. A n/ BC: Alternate Facility: 8D. Alternate Facility:
<br />>. E18A. Designated Facility: 0 8B. Alternate Facility:
<br />LL. s
<br />LE 3
<br />Z 721
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<br />Ifl;TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
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<br />CC received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />CSPrintfType Name Signature Date
<br />LEAVE AT GENERATOR
<br />
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