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e �!f-ng People. ®® Redudn9 Risk: <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 14MO-424-9300-- STANDARD MANIFEST 001 -10 -06 -STD <br />LEAVE AT GENE T <br />Genemtor's Name, Address and TelepThe Number -A 21.4n I In V 11 If. <br />1, 1 �.,s <br />S, v a I I I I 11 a 11 -11, 1 lg;� �`R 111 U lt Ill I M 1; U <br />-1 <br />7 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />6.2, PGII <br />Te- 11 - 2 i,7, I 1 2 - - - -P (3 ft, <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />, <br />1x <br />Cu Ft <br />M <br />UN3291, Regulated Medical Waste, n.o.s., <br />'Ti4 <br />0 <br />6.2, PGII <br />E, 4 1-z' <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />LU <br />UN3291 4Regulated Medical Waste, n.o.s., <br />Z <br />6.2, PGII <br />Cu Ft <br />Z3 <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />4 <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII` <br />Cu Ft <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS No, <br />I <br />Cu Ft <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />X <br />PrintecifTyped Name Signature Date <br />4. TRANSPORTER I ADDRESS: Phone #;, <br />, <br />Uj <br />Applicabie'Oermit Numbers: <br />My <br />0 <br />< <br />CL <br />(L Z <br />TRANSPORTER_ ,CEEZITIFICATION:-=fle'c"e'lpt of meclfical waste as described above. <br />PrintfType Name Signature Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />C4 <br />M!R Uji <br />Applicable Permit Numbers: <br />M <br />GJ <br />i= 0 UJIM <br />EZ <br />ZIX< <br />W= <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />Print/Type Name Signature Date <br />W <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />rx <br />Applicable Permit Numbers: <br />W <br />CC UJ , <br />0*0 <br />, z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />U., < <br />Z I.- X <br />< Z <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />El.#A. Designated Facility: 8B. Alternate Facility: ❑8C. Alternate Facility: E] 8D. Alternate Facility: <br />M <br />U. <br />u -a 5 <br />Z -23 <br />LU <br />-Z , <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 />LEAVE AT GENE T <br />