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® C, P 5 eric c Protecting 4,.! dudng Risk: IN CASE OF EMERGENCY CONTACT- CHEMTREC 1-800--42'"-:100 4 1. Ganeratc-."s Name, Address and TelephWe Number STANDARD MANIFEST 001 -10 -06 -STD In it" 1 11 iml R IN III 11 IN 111 it I JJ i 11111 A i 111'11 B 11 1 U 1111 GENERATOR'S REGISTRATION # CONTAINER TYPE 7" "C4 4 L77 1 T v 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 1110 - described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded,,and- are in all respects in proper condition for transport according to.-ppplicable international and national governmental regulation." 2C. NO. OF 2D. VOLUME CONTAINERS Cu Ft. Cu Ft. Cu Ft. Cu Ft. Cu Ft. -"Cu Ft. Cu Ft. Cu Ft. Z Cu Ft. CUSTOMER NUMBER 2A. DESCRIPTION OF WASTE UN3291, Regulated Medical Wast6, Printed/Typed Name 6.2, PGII UN3291, Regulated Medical Waste, Signature Date .00 '-J' 6.2, PGII UN3291, Regulated Medical Waste, 6.2, PGII IIE UN3291, Regulated Medical Waste, Q cc 6.2, PGII UN3291, Regulated Medical Waste, LL16 Z 6.2, PGII uj UN3291, Regulated Medical Waste, 6.2, PGII UN3291, Regulated Medical Waste, 51 !R = 6.2, PGII UN3291, Regulated Medical Waste, 6.2, PGII -medical STANDARD MANIFEST 001 -10 -06 -STD In it" 1 11 iml R IN III 11 IN 111 it I JJ i 11111 A i 111'11 B 11 1 U 1111 GENERATOR'S REGISTRATION # CONTAINER TYPE 7" "C4 4 L77 1 T v 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately I TOTALS 1110 - described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded,,and- are in all respects in proper condition for transport according to.-ppplicable international and national governmental regulation." 2C. NO. OF 2D. VOLUME CONTAINERS Cu Ft. Cu Ft. Cu Ft. Cu Ft. Cu Ft. -"Cu Ft. Cu Ft. Cu Ft. Z Cu Ft. LFULVE AT GaIERATOR ? Phone #: Applicable Permit Numbers: Printed/Typed Name Signature Date .00 '-J' 4. TRANSPORTER 1 ADDRESS: INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Z2-6: x PhoneA n Lu PrintfType Name Signature Date Applicable Permit Numbers: <0 Phone #: 51 !R = m �- 5 W cc UJ -i 0 2 0 2.,z -medical :0 Zu < Z I.- X Z TRANSPORTER,-,CERTIFICATION-.;Re'66ipt of waste as described above. Print/Type Name Signature Date 7. DISCREPANCY INDICATION J '- � -'4 Date Print/Type Name Signature � 8A. Designated Facility: LFULVE AT GaIERATOR 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: Applicable Permit Numbers: W UJM-i OM Z :n .9 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Z2-6: x PrintfType Name Signature Date 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: 51 !R = Applicable Permit Numbers: �- 5 W cc UJ -i 0 2 0 2.,z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. :0 Zu < Z I.- X < Z Print/Type Name Signature Date 7. DISCREPANCY INDICATION i 57 IQ 8A. Designated Facility: 86. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: I— M L) T U Q-, Z 798 Uj TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have I- Al I— received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LFULVE AT GaIERATOR