|
`11111C!'1019 Stericycle,
<br />Protecting People. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT. CHEMTREC 1 -VT -42-4435-06— STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Generator's Name, Address and TelephWe Number
<br />T, F_
<br />11314MIN i It 1:1193 1 A I I It III 11c I am
<br />_
<br />I'll
<br />11113 1 Its I it i 11111 ;1 i 111111 E 25 11111 _4 3 1 1111 fill 143
<br />4
<br />ICUSTOMER NUMBER -, - I- .1, . i GENERATOR'S REGISTRATION #
<br />LEVE AT IGIENE RATOR
<br />2A. DESCRIPTION OF WASTE
<br />213. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS
<br />6.2, PGIl
<br />-
<br />eS 2j
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PG I I
<br />Z
<br />Cu Ft.
<br />M
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2. PG I I
<br />ad
<br />1, 1�: 4 91 - rZ -7, 3
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T
<br />6.2, PG I I
<br />Cu Ft.
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />Z
<br />6.2, PG I I
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGI I
<br />T
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PG I I
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />6
<br />Cu Ft.
<br />Cu Ft.
<br />TOTALS 11110�
<br />57,
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
<br />"2- Cu Ft.
<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placaid, 1, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations.,
<br />V
<br />a PrintedfTyped Name —Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone
<br />Cr
<br />LU
<br />Applicable Permit Numbers:
<br />Q..
<br />M 0.
<br />0. Z
<br />TRANSPORTEFLS;ERTIFICATION:;:Re6e',pt 6fm'6dibiI waste as described above.
<br />PrintlType Name Signature
<br />Date .
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />UJ
<br />Applicable Permit Numbers:
<br />cc
<br />Uj
<br />x Ul _j
<br />HIM
<br />:OCCZ
<br />LU <
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />z
<br /><
<br />i-
<br />Print/Type Name Signature
<br />Date
<br />;; ,
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone If:
<br />wa M
<br />Applicable Permit Numbers:
<br />W
<br />M _j
<br />R50
<br />z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />4�x
<br />CC -
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />EfSA. Designated Facility: E] 8B. Alternate Facility: 8C. Alternate Facility:
<br />F] 8D. Alternate Facility:
<br />L�L
<br />E
<br />Z N
<br />LLJ
<br />E
<br />Uj
<br />N
<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 />Print/Type Name Signature
<br />Date
<br />LEVE AT IGIENE RATOR
<br />
|