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<01,10 Stericycle' <br />Protecting People. Reducing Risk. <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-.800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />l.'6enerator's Name, Address and Teleph'ffe Number <br />CUSTOMER NUMBER <br />4. nM J R 1 at k11, 1111 -13 it 5 11 4 1 4 <br />1, 14 P7 g i 1 os 4 14 4 <br />111 1; U a 9111 <br />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., <br />6.2, PGII <br />2 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.if.s. <br />% <br />6.2, PGB <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />CC <br />6.2, PGII <br />Cu Ft. <br />LLI <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />6.2 , PGII <br />Cu Ft. <br />LLI <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, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <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 ® <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 />' <br />x Printedfryped Name -Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone #,. <br />W <br />Applicable Permit Numbers: <br />0 <br />Fr <br />IL Z <br />TRANSPORTER -CERTIFICATION :,,Re661pt of medical waste as described above. <br />Print/Type Name r 1, Signature <br />Date <br />S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />N uj <br />E <br />Applicable Permit Numbers: <br />CC <br />Ui <br />D M <br />* <br />w- uZ <br />j) x <br />Uj <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />ZL <br />Printrrype Name Signature <br />Date <br />;,u <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />a a M <br />Applicable Permit Numbers: <br />a W <br />EW <br />3. 2. z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />n w< <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />A. Designated Facility: E] 8B. Alternate Facility: 8C. Alternate Facility: <br />ā‘ 8D. Alternate Facility: <br />er 'e <br />Jā€” <br />TU <br />' 91 <br />TREATMENT FACILITY: I that I have been authorized by the applicable state agency to accept untreated <br />medical wastes and that I have <br />certify <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type Name Signature <br />Date <br />