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StericyFle* IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300
<br />STANDARD MANIFEST 001 -10 -06 -STD
<br />Protecting People. Reducing Risk.
<br />i �Ganerator's Name, Address and TelephTge Number 114 In i"111WRI iI I III i 1, 11 I 11-11 IR I III III I It I I 1111
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<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />CONTAINERS
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,,
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<br />UN3291, Regulated Medical Waste, ri.o.s.,4:
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
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<br />described above by the proper shipping name, and are classified, packaged, marked and labelled/plamided, and
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
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<br />A Name Signature �, ,
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<br />Date
<br />—IPrinted/Typed
<br />4. TRANSPORTER I ADDRESS:
<br />Phone #:
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<br />UJIApplicable,Permit
<br />Numbers:
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<br />iM6idiic-al waste as described above.
<br />TRANSPORTERI,.CERTIFICATION,:;Receipt of
<br />Print/Type Name f J ignature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: y
<br />Phone
<br />x
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Z
<br />4 1.- x
<br />x
<br />Print/Type Name Signature
<br />Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />At
<br />Applicable Permit Numbers:
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<br />UJ J
<br />02 0
<br />Z
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />i.- x
<br /><
<br />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
<br />' D8A. Designated Facility:
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<br />8B. Alternate Facility:
<br />8C. Alternate Facility:
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<br />8D. Alternate Facility:
<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 />Print/Type Name Signature "bate
<br />) i LEAVE AT GENERATOR —1 ,
<br />
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