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," <br />191w'We Stericycle* <br />Protecting People. Reducing Risk. <br />I <br />OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 <br />1. Generator's Name, Address and Telephone Number <br />m <br />(CUSTOMER NUMBER <br />7 GENERATOR'S REGISTRATION # <br />STANDARD MANIFEST 001 -10 -06 -STD <br />11 € pajoll ! , 4 <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />'— <br />CONTAINERS <br />Phone <br />6.2, PGII <br />i. <br />I, 2:j 1 -j Z j f 4 f�-,Lk 1 4 1 z; a! Tub 3 . SP r -a ft-- <br />Z; <br />911- <br />Ff <br />Applicable PermitNumbers: <br />< 0 <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cn <br />6.2, PGII <br />7,51 1: 7� 4al <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s.,-7� <br />- <br />4, 9 <br />Signature <br />6.2, PG I I <br />,7 <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s.-, <br />tR cc <br />6.2, PGII <br />Applicable Permit Numbers: <br />5 W <br />OLUC <br />Q. 2 Z <br />Cu F <br />UN3291, Regulated Medical Waste, <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />6.2, PG I I <br />Print/Type Name Signature. <br />Date <br />W <br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />Applicable Permit Numbers: <br />0 Uj -.1 <br />0.20 <br />6.2, PGII <br />4 4 G a 1 'P'Lak, B 5 4 <br />WME <br />ate= <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />Print/Type Name Signature <br />Date <br />6.2, PGII <br />7 <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />8A. Designated Facility: Lj 8B. Alternate Facility: 8C. Alternate Facility: <br />6.2, PGII <br />5 G4 <br />Cu F <br />ZrF i -4. <br />LL <br />45 <br />Z -81 <br />Cu F1 <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />LS 00- <br />JC t10 �7 C V <br />,is-qL—nq A-4 —4 —11-4W <br />drrihPd qhnvp. hv tha nrnnar Qhinninn n— aro ninecifi-4 ——1�1-- <br />Cu R <br />are in all respects in proper condition for transport according to applicable in ternational and national governmental regulations." <br />�j <br />A Printed/Typed Name ��- ; I � ` I- , i � " I , C <br />Signature Date <br />cc' <br />4. TRANSPORTER I ADDRESS: & I <br />Phone <br />911- <br />Ff <br />Applicable PermitNumbers: <br />< 0 <br />Cn <br />IL Z <br />TRANSPORTER.-C-ERT-IFICATIO14:.QR66elpt of inddUal waste as described above. <br />Print[Type Name/ <br />Signature <br />Date -�L= <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />Ui <br />tR cc <br />Applicable Permit Numbers: <br />5 W <br />OLUC <br />Q. 2 Z <br />cncc<x <br />ZUj <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />Print/Type Name Signature. <br />Date <br />W <br />6. INTERMEDIATE HANDLER 3 TRANSPORTER 3 ADDRESS: <br />Phone #: <br />M!R , <br />U.1 <br />�aw <br />Applicable Permit Numbers: <br />0 Uj -.1 <br />0.20 <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />WME <br />ate= <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />1 V, <br />8A. Designated Facility: Lj 8B. Alternate Facility: 8C. Alternate Facility: <br />E) BID. Alternate Facility: <br />M <br />ZrF i -4. <br />LL <br />45 <br />Z -81 <br />h� <br />Q V <br />LU <br />JC t10 �7 C V <br />L; <br />W <br />I= <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated <br />�nedical wastes and that I have <br />1-- <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />PrintlType Name Signature <br />Date <br />LEAVE AT MEMERATOR <br />