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111CO-0 <br />Slericy IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />4" 1_', <br />LEAVE AT GENEFATIOR <br />1., Generator's Name, Address and Telephone Number 17 <br />al <br />fig <br />I 1131 <br />CUSTOMER NUMBER i., i y GENERATOR'S REGISTRATION # <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 />B i J -17 14-(pa-t;h" 4-4 rlft", <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />ear_ <br />Cu Ft. <br />X <br />UN3291, Regulated Medical Waste, n,o.s., <br />4 9f <br />6.2, PGII <br />.Ji� <br />Cu Ft. <br />Q <br />UN3291, Regulated Medical Waste, n.o.s <br />4 A-� S <br />" <br />X <br />6.2, PGII <br />Cu Ft. <br />W <br />UN3291 Regulated Medical Waste, n.o.s., <br />— <br />Z <br />Uj <br />6.2, PG1i ► <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGI i <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />-T <br />m,4 <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ®C,; <br />Cu Ft. <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 />xPrintecIrryped Name Signature Date <br />4. TRANSPORTER I ADDRESS: Phone <br />UJI <br />Applicable Permit Numbers: <br />4 0 <br />I X, <br />IL <br />U) <br />IL Z <br />TRANSPORTER .CERTIFICATION: Receipt of mediq`al waste as describpA. above. <br />Print/Type Name./ Signature Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone <br />Applicable Permit Numbers: <br />c <br />:)20 <br />aXZ <br />w< <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />E = <br />Print[Type Name Signature Date <br />W <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />UJ <br />Applicable Permit Numbers: <br />UJ -J <br />)*0 <br />z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />W <br />PrintlType Name Signature Date <br />7. DISCREPANCY INDICATION <br />& <br />8A. Designated Facility: 8B. Alternate Facility: Q 8C. Alternate Facility: Ej 8D. Alternate Facility: <br />vi: nlu 6i <br />4, <br />sH <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 />Print/Type Name Signature Date <br />LEAVE AT GENEFATIOR <br />