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<br />i Protectin People. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT CHEMTREC 1 4-0051 STANDARD MANIFEST 001 -10 -06 -STD
<br />TREATMENT FACILITY: I certify that I have been authorized by the apply agency j a ,.pt untreat -: medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement oui. I that aut .tion.
<br />Print/Type Name Signature _. Date
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<br />1. Generator's Name, Address and Teleph0 a Number I 1 141 ; ; I , d M T 1
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<br />CUSTOMER NUMBER T -� j GENERATOR's REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />REGULATED MEDICAL WASTE, n.o.s.,6.2,CONTAINERS
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<br />3. Generator's Certification: '9 hereby declare that the contents of this consignment are fully and accurately TOTALS Do -_ Cu Ft
<br />described
<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 />Printed/Typed Name ^ ..:°s., Signature Date
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<br />4. TRANSPORTER,1 ADDRESS: Phone # _ m
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<br />Applicable JPermlt Numbers
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<br />TRANSPORTER.�CERTIFICATION: Receipt of medical waste as described above.
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<br />YP Signature Date /
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Print/Type Name Signature Date
<br />7. DISCREPANCY INDICATION
<br />O SA. Designated Facility:
<br />F] 8B. Alternate Facility: 8C. Alternate F- lity°
<br />❑ 8D. Alternate Facility:
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<br />TREATMENT FACILITY: I certify that I have been authorized by the apply agency j a ,.pt untreat -: medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement oui. I that aut .tion.
<br />Print/Type Name Signature _. Date
<br />
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