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<br />Imp Protecting People. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Gen&ator's Name, Address and TelephMe Number
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<br />GENERATOR,s REGISTRATION #
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<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 111P
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<br />described above by the proper shipping name, and are classified, packaged, marked and label led/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
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
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<br />TRANSPORTER CERTIFICATION :,Receipt of ftledicial waste as described above.
<br />Print/Type NameSignature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 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 />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />E18A. Designated Facility: 8B. Alternate Facility: E] 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 medical wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />Date
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