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Stericye!e, IN CAkE, OF EMERGENCY CONTACT CHEMTREC 1-800-424-9300
<br />STANDARD MANIFEST 001 -10 -06 -STD
<br />protecting People. Reducing Risk:
<br />Renerator's Name, Address and Telephone Number 1 V41 A ivit S4+o 11 11 M 411
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<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />LEAVE A3 03-77"E . T -,
<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
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<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 Na meSignature `" `
<br />Date r '�-, -
<br />4.TRANSPORTER 1 ADDRESS:
<br />Phone #ro
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER-CERTIFICATION.'Recei Yoe medical waste as described above
<br />Print/Type Name Signature` 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 />Print(Type Name Signature
<br />Date
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<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 />Print/Type Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />E] 8A. Designated Facility: 8B. Alternate Facility: F-1 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
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />PrintRype Name Signature
<br />Date
<br />LEAVE A3 03-77"E . T -,
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