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4,101,10 Stericycle' <br />Pmtecting People. Reducing <br />I I <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 ­__-__;TAZARD MANIFEST 001 -10 -06 -STD <br />LEAVE AT GENERATOR <br />1. Generator's Name, Address and Telephone' Number <br />I !I I , �� 1111111 <br />7-, r', t§! 7 1 1 EI A 4 3 F Val 1114 A AA a 01 494 <br />R <br />'j <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS <br />6.2, PG I I <br />j 'TT111-112atM! 44 Gal T -ab (3-9 c-il Ct"; <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGI I <br />�71 5 - t <br />Cu Ft. <br />IM <br />UN3291, Regulated Medical Waste, n.o.s., <br />B 4 !� 4 '� , -) �7 :9 - Z4 9- <br />P6.2. <br />PGll <br />Cu Ft. <br />4 <br />UN3291, Regulated Medical Waste, n.o.s,,___T­ <br />-,- a 1 7 51 <br />IX <br />6.2, 131311 <br />Cu Ft. <br />UJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />6.2, PG I I <br />Cu Ft. <br />tJJ <br />Vt <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PG I I <br />c �711 7� ;_n <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGlI <br />6 4 <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 111. <br />Cu Ft. <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 />xPrintedfTyped Name Signature Date <br />4. TRANSPORTER DDRE S: Phone <br />WR3 <br />Applicia'ble Permit Numbers: <br />0 <br />f <br />(L <br />0. Z <br />TRANSPORTER-L-ERTIFICATION-.f3e6bipt of medical waste as described above. <br />A <br />Print/Type Name Vk' ,7 Signature 7 Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />.4 <br />.5 a M <br />Applicable Permit Numbers: <br />UJ _J <br />Wo B <br />b <br />zic-Z <br />UJ C <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />E a M <br />Applicable Permit Numbers: <br />; 5W <br />UJ J <br />I a <br />z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z Uj <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />T 'J <br />$A. Designated Facility: 8B. Alternate Facility: E] 8C. Alternate Facility: 8D. Alternate Facility: <br />Ej <br />�7 "A <br />_J UU �tf <br />3 %t7 <br />-a E <br />,U <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 />PrintlType Name —Signature Date <br />LEAVE AT GENERATOR <br />