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Stericycie' Protecting People. Reducing Risk: IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD 1. Generator's Name, Address and TaieplWe Number NUMBER - � 1 5 �-� �-. GENERATOR'S REGISTRATION # 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s., CONTAINERS Printed(Typed Name Signature 6.2, PG I I T B 14 - B 1T 14 - A -T a 1�kA1 4 G a I T -,-Ab 3" tu 4. TRANSPORTER 1 ADPRESS: Cu F UN3291, Regulated Medical Waste, n.o.s., Applicable Permit Numbers: 6.2, PGII f 2 4� I, Z -ht < 0 Cu R UN3291, Regulated Medical Waste, n.o.s., Z. CL LE 6.2, PGII :5 Z j Ix Print/Type Name Signature Date Cu R UN3291, Regulated Medical Waste, n.os., 4-:'t Applicable Permit Numbers: 6.2, PGII Cu Ft UN3291, RegPlated Medical Waste, n.o.s., Z 'F U)MZ Z UJI ex INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 6.2, PG I I G�,4L Print/Type Name Signature Date Cu Ft UN3291, Regulated Medical Waste, n.o.s., Phone #: 6.2, PGII T LLL INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Cu Ft JN3291, Regulated Medical Waste, n.c.s., < cc 3 6.2, PGII Date Cu Ft UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII !�,4 Gal- 3. 0 Cu Ft jr Cu Ft. 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately LS ripqrAhwi ;ihnvp by the nrnnar chi—i— n— canrl — Mmacifinq —1,—A —A -A —4 Cu Ft, 7. DISCREPANCY INDICATION >- :� -,[ �,OA. Designated Facility: 8B. Alternate Facility: j 8C. Alternate Facility: E] 8D. Alternate Facility: F- Ew Ig LL Z 33 uj I& T TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated 'medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LF -All E AT GENE R AT 0R are in all respects in proper condition for transport according to applicable international. and national governmental regulations." Printed(Typed Name Signature AX Date 4. TRANSPORTER 1 ADPRESS: -j.ione W Applicable Permit Numbers: < 0 Z. CL LE (L Z TRANSPORTER-.C-ERTJFICATION.-,Rei�elpf'�ti�idic:aI waste as described above Ix Print/Type Name Signature Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone CM UJI x Applicable Permit Numbers: �aw LU -.1 0 0.20 U)MZ Z UJI ex INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date tu 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: Applicable Permit Numbers: 0 W INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. ,,z z LU I - < cc 3 PrIntfType Name Signature Date 7. DISCREPANCY INDICATION >- :� -,[ �,OA. Designated Facility: 8B. Alternate Facility: j 8C. Alternate Facility: E] 8D. Alternate Facility: F- Ew Ig LL Z 33 uj I& T TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated 'medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LF -All E AT GENE R AT 0R