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<br />Protecting People. Reducing Risk.
<br />IN CASE OF EMERG7N!Y CONTACT: CHEMTREC 11400,422r-9300 STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Generator's Name, Address and TelepWe Number
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<br />LEAVE AT GENERATOR
<br />CUSTOMER NUMBER r7 1, � � - - -. k_j' ,al 1 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 />S. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 110 -
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placardecl, and
<br />are in all respects in proper conditionjd or transport according to applicable international annational gov6rnmentaf-rag�lifidne,,.,,,",
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<br />Name —Signature
<br />—Date
<br />4. TRANSPORTER 1 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTEkCEATIFItATIOK"Re&pt of medical waste as described above.
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<br />Print/Type Name ii- t"%' el Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />[38A. Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility:
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<br />TREATMENT FACILITY: I certify thatI 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 />Print/Type Name Signature
<br />Date
<br />LEAVE AT GENERATOR
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