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• StericyScle' IN CASE OF EMERGENCY CONTACT CHEMTREC 144 Xf4:-9300 STANDARD MANIFEST 001 -10 -06 -STD
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<br />?"'/E AT GEM TO
<br />1. Generator's Name, Address and Tele p ne Number III, till al 1"11T I i S,31 1 ,6 1 IN14111 ll ] 1111
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<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately T®YACs ®
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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 />4. TRANSPORTER 1 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTERZERTIFICATION "Receipt of medical waste as described above.
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<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:,
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility:
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<br />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 />received the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />Date
<br />?"'/E AT GEM TO
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