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<br />®® Prot�"�PIe. Reducing Risk:
<br />IN CASE OF EMERGENCY CONTACT CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
<br />x el M." I r: I aenny ulat I nave Deen autnonzea Dy the appucaole 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 />Print/Type Name
<br />Signature
<br />LEAVE AT OENERWR.
<br />Date
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<br />CUSTOMER NUMBER rte,' ;},rv. q -j GENERATOR'S REGISTRATION # ..
<br />2A. DESCRIPTION OF WASTE
<br />2B• CONTAINERTYPE
<br />2C. NO. OF
<br />2D. VOLUME
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ® 'v
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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."
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<br />Yp Signature Date
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<br />4. TRANSPORTER 1 ADDRESS: ' ''PhoneLU
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<br />TRANSPORTERZERTIFICATION: Receipt of medieal waste as described above.
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<br />7. DISCREPANCY INDICATION
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<br />OVA: Designated Facility:
<br />❑ 8B. Alternate Facility:
<br />8C. Alternate Facility:
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<br />x el M." I r: I aenny ulat I nave Deen autnonzea Dy the appucaole 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 />Print/Type Name
<br />Signature
<br />LEAVE AT OENERWR.
<br />Date
<br />
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