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010,019 Stericycle IN CASE OF EMERGENCY CONTACT: CHE MTFI,I P 1-800 424-930 Protecting People. Reducing Risk. 1. Generator's Name, Address and TelepTone Number -0 U 7 CUSTOMER NUMBER GENERATOR'S REGISTRATION # STANDARD MANIFEST 001 -10 -06 -STD E Z, W IN A I R11 V 111 N 1 A i i 13 1 If 'ic 1111 2A. DESCRIPTION OF WASTE 213. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s., 4_ 117"P1 4 f4` m 4,4 Ga.1 '?!xb Rc CONTAINERS Name Signature 6.2, PGII 4. TRANSPORTER 1 ADDRESS: Cu F UN3291, Regulated Medical Waste, n.o.s., W >- 6.2. PGII. Applicable Permit Numbers: a: < 0 Cu F UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII TRANSPORTEWCEPTIFlaA'rio-N,.-'—rfecdiot Of medical waste as described above. Cu F UN3291, Regulated Medical Waste, n.o.s., Print/Type Name Signature "2 6.2, PGII 5. INTERMEDIATE HANDLERTRANSPORTER 2 ADDRESS: Cu R UN3291, Regulated Medical Wasie, n.o.s., UVA 6.2, PGII Applicable Permit Numbers: RUJ UJ Cu F1 UN3291, Regulated Medical Waste, n.o.s., -a oi LZJ 4 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 6.2, PGII x Cu R UN3291, Regulated Medical Waste, n.o.s., Date co LU 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: 6.2, PGII WM!R � 5 ul M Cu Ft UN3291, Regulated Medical Waste, n.o.s., R 6.2, PGII WxZ z LU < I.. X Cu Ft -x F 3 Print/Type Name Signature Cu Ft 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately ripQrriharq nhn%m by tho nrnn.r chinninn n— onA — r1—;fief —L— nc rf —[—A —4 1,kMIA I TOT,4 Cu Ft C.) < 9 LL 3: E Z S: Uj Uj cc 7. DISCREPANCY INDICATION 0A. Designated Facility: 18B. Alternate Facility: -S, 8C. Alternate Facility: 8D. Alternate Facility: r. TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LVE AT CEI are in all respects in proper condition for transport according to a pplicable international and national governmental regulations.' xPrinted/Typed Name Signature _j Date 4. TRANSPORTER 1 ADDRESS: Phone #e W >- Applicable Permit Numbers: a: < 0 IX U CL Z TRANSPORTEWCEPTIFlaA'rio-N,.-'—rfecdiot Of medical waste as described above. Ll Y Print/Type Name Signature "2 Dat( 5. INTERMEDIATE HANDLERTRANSPORTER 2 ADDRESS: Phone #: CM W UVA m Applicable Permit Numbers: RUJ UJ 020 zlrz< , INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. P Z x Print/Type Name Signature Date co LU 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: WM!R � 5 ul M Applicable Permit Numbers: 0 UA -J 2 0 R INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. WxZ z LU < I.. X -x F 3 Print/Type Name Signature Date C.) < 9 LL 3: E Z S: Uj Uj cc 7. DISCREPANCY INDICATION 0A. Designated Facility: 18B. Alternate Facility: -S, 8C. Alternate Facility: 8D. Alternate Facility: r. TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LVE AT CEI 18B. Alternate Facility: -S, 8C. Alternate Facility: 8D. Alternate Facility: r. TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LVE AT CEI