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<*.*6 SteiricycW IN CASE OF EMERGENCY CONTACT:-CHEMTREC 11-dbb"211�9300 STANDARD MANIFEST 001 -10 -06 -STD <br />Protectir. People. Reducing Risk. <br />1. Generator's Name, Address and TelephWe Number fl! 1054 MI 111; 1 1s I i 1111411 Bill lilt; Ili 10 <br />A a � 1 141 %sa <br />`*1-151 i 4 , A <br />11, r & <br />7, <br />4 <br />T <br />(CUSTOMER NUMBER <br />GENERATOR'S REGISTRATION # <br />LEAVE AT QZNERATOR <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS <br />6.2, PGII <br />Cu Ft, <br />UN3291, Regulated Medical Waste, n.o.s., <br />7 -- <br />6.2, PGII <br />- - <br />Cu Ft. <br />cc <br />UN3291, Regulated Medical Waste, n.o.s., <br />4-z <br />r <br />0 <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />6.2, PGII <br />Cu Ft. <br />LLJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />Wt <br />6.2, PGII <br />4 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />T <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />G <br />Cu Ft. <br />ej i-11, <br />Cu Ft. <br />TOTALS <br />I <br />7-' <br />3. Generator's Certification: "I hereby declare 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 />4� <br />x Printedfryped Name _-Signature <br />Date 2 <br />4. TRANSPORTER I ADDRESS: <br />Phone <br />CCF. <br />,#., <br />UU <br />Alicable Permit Numbers: <br />pp <br />'A <br />Z< <br />TRANSPORTE"ERTIFICATIONRece-fpt of m6&41 waste as described above. <br />PlrinttType Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone <br />UJI <br />t -K M <br />Applicable Permit Numbers: <br />5L4 <br />w0 <br />M <br />m Z < <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 #: <br />IU <br />!R -M <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />UJI <br />I.- <br />PrintlType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />T <br />E38A. Designated Facility: 8B. Alternate Facility: Q 8C. Altemate Facility: <br />8D. Alternate Facility: <br />r <br />j <br />-6 <br />a; <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 <br />Date <br />LEAVE AT QZNERATOR <br />