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<br />I SE OF EMERGENCY CONTACT: CHEMTREC 1-800-42 i 4-9300 STANDARD MA , NIFEST 001 -10 -06 -STD
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<br />LEAVE AT GENERATOR
<br />1. Generator's Name, Address and Telephone Number, i M
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<br />CUSTOMER NUMBER TF, I CGENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<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 110- 1
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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 />4. TRANSPORTER I ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTEFtCERTIFICATION FAFIC eii5t ofm6cli6afwaste as described above.
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<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
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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 />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />7. DISCREPANCY INDICATION
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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 />received the above indicated wastes in accordance with the requirement outlined in that authorization.
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<br />Date
<br />LEAVE AT GENERATOR
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