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<br />INCE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
<br />1. Generator's Name, Address and Telephone Number f
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<br />CUSTOMER NUMBER -r s
<br />GENERATOR'S REGISTRATION #
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<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: '9 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:'
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<br />Printed/Typed Name - - Signature
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<br />4. TRANSPORTER 1 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION Receipt of meiiieal waste as described above.
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<br />Print/Type Name -, r d .+wis alc Signature _ ____...._..
<br />Date
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<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.
<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 />tjr 8A. Designated Facility: 813. Alternate Facility: ❑ 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
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<br />the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />Print/Type Name Signature
<br />Date
<br />LEAVE AT OE EPATOR
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