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<br />.ee Protecting People. Reducing Risk.
<br />1.. Generator's Name, Address and Tele one Number
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<br />.—STANDARD, MANIFEST 001 -10 -06 -STD
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 01
<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 />4 CATION:Fleddipt of hielidal waste as described a;,�
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<br />Print(Type Name '1,hCf'5'r';' (I
<br />Signature
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<br />V) MLLI x -C INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />Phone #: ]Ul
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
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<br />CUSTOMER NUMBER j GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 01
<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
<br />cc CTRANSPORTER I ADDRESS:
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<br />Print(Type Name '1,hCf'5'r';' (I
<br />Signature
<br />— 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />CM LU
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<br />rr Lau Ui
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<br />Z22Z
<br />V) MLLI x -C INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature
<br />Date
<br />Phone #: ]Ul
<br />Applicable Permit Numbers:
<br />Date
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
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<br />_j Applicable Permit Numbers:
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<br />Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Printfrype Name Signature Date
<br />7. DISCREPANCY INDICATION
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<br />8A. Designated Facility: �8B. Alternate Facility: ❑ 8C. Alternate Facility: ❑ 8D. Alternate Facility:
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<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 />Printrrype Name Signature Date
<br />L—EJ8.11E AT GENERATOR
<br />
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