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<br />IN CASE OF EMERGENCY CONTACT CHEMTREC 1"600.424-9300' STANDARD MANIFEST 001-10-06-51u
<br />1. Ger*erato-vis Name, Address and Telepha!
<br />Number Y� t
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<br />L I- E AT GENERATOR
<br />CUSTOMER NUMBER" 1, 1 t - "',.._ I, r - I GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS /'
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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:'
<br />PrintedlTyped Name Signature
<br />4. TRANSPORTER 1 ADDRESS:
<br />Date
<br />Phone # w r w a
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<br />Applicable Permit Numbers:
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<br />TRANSPORTEFt'CERTaFICATION Peceiipt of med cal waste as described above.
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<br />Date
<br />Print/Type Name �. - Signature
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:`
<br />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
<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 medical waste as described above.
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<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />Q 8A. Designated Facility: 8B. Alternate Facility: E 8C. Alternate Facility:
<br />8D. Alternate Facility:
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<br />TREATMENT FACILITY: I certify that 1 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.
<br />Print/Type Name Signature
<br />Date
<br />L I- E AT GENERATOR
<br />
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