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'ericycle' <br />=cling People. Redwing RiA._rt <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />n 1 7 <br />All - - - - - - - <br />)rator's Name, Address and TelelphWe Number <br />1511 If <br />1 <br />11 <br />R IMAM <br />13111 <br />GENERATOR'S REGISTRATION # <br />IJIU111111141111111 1PIM141111,311 <br />t R I I <br />1 1 21 14 i11 it ' <br />LEAVE AT GENERATOR <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINEIRTYPE <br />2C. NO. OF <br />2D. VOLUME <br />CONTAINERS <br />UN3291, Regulated Medical Waste, n.o.s., <br />B � 14 - il' 3 -1 f t sh 44, G&I Tub Ma <br />Cu Ft.. <br />6.2, PGII <br />- <br />UN3291, Regulated Medical Waste, n.o.s., <br />`7 <br />7Z <br />Cu Ft. <br />6.2, PGII <br />M <br />UN3291, Regulated Medical Waste, n.o.s., <br />t, 4 _9 <br />f- <br />la if <br />Cu Ft. <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />7, 1 7) <br />cc <br />6.2, PGII <br />Cu Ft. <br />LU <br />UN3291, Regulated Medical Waste, n.o.s., <br />T <br />Z <br />6.2, PGII <br />1!:' <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />.1 4 4 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />71.'14" i <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Ga! ;57 <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 1111,- <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 />xPrinted/Typed Name ---Signature <br />4. TRANSPORTER 1 ADDRESS: <br />Date <br />Phone #; 'r - <br />UJI <br />Applicable Permit Numbers: <br />< 0 <br />CL <br />rc (n <br />0. Z <br />TRANSPORTER,;CERTIFICATIOttpiece )t of 'ih;dkil waste as described above. <br />Lsignature <br />is <br />Date <br />PrintlType Name <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Lu <br />Applicable Permit Numbers: <br />aW <br />UJI <br />izz <br />zculi --x <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />.1 <br />PrintfType Name Signature <br />Date <br />W <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />x <br />Applicable Permit Numbers: <br />5!i <br />a W, <br />UJ <br />0.a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Uj <br />Z I'= <br />Z <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />n1 -8A:Designated Facility: E] 8B. Alternate Facility: Lj4(;. Alternate Facility: <br />8D. Alternate Facility: <br />7-: ' <br />TE Ith <br />LL— <br />A -'j <br />I.— gg <br />A E <br />Ty <br />pp <br />Z <br />fid"` <br />�'j <br />Lu <br />t 4 <br />LuQ. <br />af <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 />= 8. <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Printrrype Name Signature <br />Date <br />LEAVE AT GENERATOR <br />