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<br />Protecting People. Reducing Risk:
<br />IN CASE OF EMERG�'R,,3Y CONTACT: CHEMTREC 1.800-424-9300— STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Generator's Name, Address and TelephoM5 Number
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<br />CUSTOMER NUMBER -� 1, - � 1' "', � -;;-i I GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291, Regulated Medical Waste, n.o.s.,i4t
<br />3 ?
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<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, nos.,
<br />4
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<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,5,
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />Z
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />71, .7
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PGII
<br />1 '7
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 10-
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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 />ASignature Printed/Typed Name S
<br />4. TRANSPORTER 1 ADDRESS:
<br />Date
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER-•CERTIFICAT[ONRe'c'o�ipt 66�6(flcal waste as described above.
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<br />Print(Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<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 />8A. Designated Facility: E] 8B. Alternate Facility: � 8C. Alternate Facility:
<br />8D. Alternate Facility:
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
<br />LEAVE AT GaIERATOR
<br />
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