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<br />• Protecting People. Reducing Risk.
<br />IN CASE OF EMERGENCY CONTACT.-CHEMTREC 1-80)0424-9300STANDARD MANIFEST 001 -10 -o6 -STD
<br />Lam, IIE AT GENERATOR
<br />1. GeneratSr's Name, Address and Teleplponre Number fil RMUNITID11 1111,114, � 11IM114,141SIM a YLINII N 41,t
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<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
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<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 ITOTALS
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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 />TRANSPORTER�CEFtTiriCATIONReceipt 61 hriecli`I 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 />7. DISCREPANCY INDICATION
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<br />FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical
<br />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 />Lam, IIE AT GENERATOR
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