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<br />OF EMERGENCY CONTACT CHEMTREC
<br />1. Generator's Name, Address and Telephone Number
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<br />CUSTOMER NUMBER _ j ; ' GENERATOR'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 TOTAL700-
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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."
<br />Printed/Typed Name $ ,i w" - `# `> _ `r Signature `-_
<br />Date
<br />4. TRANSPORTER 1 ADDRESS:
<br />Phone #;,^
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: -Receipt of=meilicaiwaste as described above.
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<br />Print/Type Names ;P Signature
<br />Date $/
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: ' 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 />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: 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 />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
<br />wastes and that I have
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<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT GENERATOR
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