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O!• <br />1. PStericycie' <br />Protecting People. Reducing RiA. <br />IN CASE OF EMERGENCY CONTACT. CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />1. Generator's Name, Address and TelephoTeF Number <br />T 7 <br />lit 11343141! <br />GENERATOR'S REGISTRATION # <br />11111 3H HUMERI I R I III 1012 1 ail <br />2A. DESCRIPTION OF WASTEI I <br />CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />CONTAINERS <br />UN3291, Regulated Medical Waste, n.o.s., <br />TD14-- f TP14­ Uath)l J -j GzA1 5.9 c -t; ft.) <br />Cu Ft. <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />Cu Ft. <br />I= <br />6.2, PG I I <br />UN3291, Regulated Medical Waste, n.o.s <br />`J <br />T� <br />Cu Ft, <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s.,Cu <br />Ft. <br />6.2, PGII <br />UJI <br />UN3291, Regulated Medical Waste, n.o.s., <br />r* a <br />3 - <br />Cu Ft. <br />Z <br />6.2, PGII <br />LLI <br />Medical Waste, n.o.s., <br />UN3291, Regulated Me <br />A U <br />Cu Ft. <br />6.2. PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu Ft. <br />6.2, PGII <br />f] <br />UN3291, Regulated Medical Waste, n.o.s., <br />44_ 2ca <br />Cu Ft. <br />6.2, PGII <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS11111 <br />I Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placaided, and <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations.' <br />xPrinted/Typed Name —Signature <br />4. TRANSPORTER I ADDRESS. <br />y A <br />ate <br />Phone #: <br />cc <br />LU <br />Applicable Permit Numbers: <br />4 0 <br />CL <br />to <br />Z< <br />TRANSPORTERZERTIFICATION:;Receipt of ffigclibal waste as described above. <br />Print/Type Name Ln— Signature <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Date <br />Phone <br />4 LU <br />Applicable Permit Numbers: <br />'U!R cc <br />EBUJ <br />W -OJ <br />:) <br />36cl < 2, <br />5 W= <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />M <br />g t2 <br />PrintfType Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers: <br />W <br />W5 <br />x .J <br />22 0 <br />Z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />X -C <br />LU <br />Z <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />BA. Designated Facility: 8B. Alternate Facility: ❑ 8C. Alternate Facility: <br />8D. Alternate Facility: <br />T <br />7 <br />J `i! <br />A. <br />Z 1 <br />7 4 <br />7 <br />-it t <br />�AA I D <br />81 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated <br />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 />