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<br />• Steriicych' IN CASE OF EMERGENCY CONTACT. CHEMTREC_1-80
<br />.i Protecting People. Reducing Risk.'
<br />1. Generator's Name, Address and Telephone Number
<br />7,_ D
<br />7; 7'
<br />CUSTOMER NUMBER
<br />GENERATOR'S REGISTRATION #
<br />STANDARD MANIFEST 001 -10 -06 -STD
<br />11
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<br />2A. DESCRIPTION OF WASTE
<br />2B.
<br />CONTAINER TYPE
<br />2C. NO. OF
<br />2D.
<br />VOLUME
<br />EJBA. Designated Facility:
<br />UN3291, Regulated Medical Waste, n.o.s.,CONTAINERS
<br />❑ 8C. Alternate Facility:
<br />Name —Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />6.2, PGII
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<br />(*B -j 7.R 11- a2 a th", 4 4 Sal 1,12a C-ta �)
<br />-'Permit Numbers.
<br />Applicable
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<br />33
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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-,
<br />certify that I have been authorized by the applicable
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<br />medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />6.2,PGII
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<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />T 5
<br />2 f,
<br />Date
<br />6.2, PGII
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
<br />-7
<br />Cu Ft.
<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6,2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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<br />UN3291, Regulated Medical Waste, n.o.s.,
<br />6.2, PGII
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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 />TOTALS 071�
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<br />Z TRANSPORTER-CERTJ ICATI[OW�Recolptof thbdical waite as described above.
<br />Print/Type Name Sez� /ggnature f « P Date — I
<br />S. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />CM LU t,
<br />W !R cc Applicable Permit Numbers:
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<br />0 LU
<br />ZLU= CL2Z
<br />-x< INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/ Type Name Signature Date
<br />W 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />MW
<br />a � L4 x Applicable Permit Numbers:
<br />�
<br />0wo
<br />M , INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Lu
<br />Print/Type Name Signature Date
<br />17. DISCREPANCY INDICATION
<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations."
<br />y
<br />XPrinted/Typed
<br />EJBA. Designated Facility:
<br />88. Alternate Facility:
<br />❑ 8C. Alternate Facility:
<br />Name —Signature
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #:
<br />U.1
<br />-'Permit Numbers.
<br />Applicable
<br />j°ma
<br />33
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<br />c it --mm, tL�ic
<br />78
<br />'T 77 W
<br />-7
<br />Z TRANSPORTER-CERTJ ICATI[OW�Recolptof thbdical waite as described above.
<br />Print/Type Name Sez� /ggnature f « P Date — I
<br />S. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone #:
<br />CM LU t,
<br />W !R cc Applicable Permit Numbers:
<br />Uj
<br />0 LU
<br />ZLU= CL2Z
<br />-x< INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/ Type Name Signature Date
<br />W 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
<br />MW
<br />a � L4 x Applicable Permit Numbers:
<br />�
<br />0wo
<br />M , INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Lu
<br />Print/Type Name Signature Date
<br />17. DISCREPANCY INDICATION
<br />LEAVE AT GENERATOR
<br />y
<br />EJBA. Designated Facility:
<br />88. Alternate Facility:
<br />❑ 8C. Alternate Facility:
<br />8D. Alternate Facility:
<br />_j
<br />j°ma
<br />33
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<br />J 0
<br />78
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<br />TREATMENT
<br />FACILITY: I
<br />certify that I have been authorized by the applicable
<br />state agency to accept untreated
<br />medical wastes and that I have
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Printf Type Name
<br />Signature
<br />Date
<br />LEAVE AT GENERATOR
<br />
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