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<br />4,100,0 Protecting People. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT: CHE Jp STANDARD MANIFEST 001 -10 -06 -STD
<br />AMC
<br />1. Gener'ator's Name, Address and Telepho Number �p� I + I • + }
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<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
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<br />CUSTOMER NUMBER -
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<br />2A. DESCRIPTION OF WASTE
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />.... 1
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />;.
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s,
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<br />Signature
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
<br />W
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />UN3291, Regulated Medical Waste, n.o.s.
<br />[] 86. Alternate Facility: �❑
<br />8C. Alternate Facility:
<br />6.2, PGII
<br />GENERATOR'S REGISTRATION #
<br />CONTAINER TYPE
<br />2C. NO. OF 2D. VOLUME
<br />CONTAINERS
<br />'-" y' ,,, s:t r ,. F .- s "i a..a;' ii. zata ..9 ..,.. , s '.+
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />Cu Ft.
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Cu Ft.
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<br />Cu Ft.
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<br />Cu Ft.
<br />Cu Ft.
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<br />TOTALS
<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately ' , /C� 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 />Printed/Typed Name Signature ? Date
<br />4. TRANSPORTER 1 ADDRESS: Phone # _
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<br />W z' Appllc$able'`Permit-Numbers.
<br />E¢ TRANSPORTER;,,CEFiTIFICATION:�eGeipt of medical waste as described above.
<br />Print/Type Name ;+- .-. Signature Date /
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
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<br />ias
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<br />i w i INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />iz
<br />Print/Type Name Signature
<br />Phone #:
<br />Applicable Permit Numbers:
<br />Date
<br />;'au
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:..
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<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Signature
<br />bate
<br />Print/Type Name
<br />7. DISCREPANCY INDICATION
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<br />R'8A. Designated Facility:
<br />[] 86. Alternate Facility: �❑
<br />8C. Alternate Facility:
<br />8D. Alternate Facility:
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<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 />Signature
<br />Date
<br />Print/Type Name
<br />LEAVE AT GENERATOR i
<br />
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