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99 Stericycle* Protecting People. Reducing Risk.' 1. Generator's Name. Address and TelepiGon 7 �7 NUMBER U OF EMERGENCY CONTACT. CHEMTREC 1-800-424 MI Number , U yt I J il ` GENERATOR'S REGISTRATION # STANDARD MANIFEST 001 -10 -06 -STD �7 195, If 1 9 01 3 1 111 i 11 ! I i I Ell 101 W all i six R 14 .1a gel g 3; Z1 .11 it I I W V V 51 it. I I Dig if ltivi 110!"1 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s., CONTAINERS 6.2. PGII `14 ub 1:� -fr: i I � — - � _-, 'a, - 1 J, TP 1 f- -�� at -1-1 4 4 9 a. 1 2 A Printedrryped Name :Signature Date Cu F UN3291, Regulated Medical Waste, n.o.s., Phone LU 6.2, PGII T 1 a 1�. 5 - "7 Cu F UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII .---7-7 4 K a. Z TRANSPORTER: tERTIIFICATION:-Rec6i4of",ffteAi(�alwas1'e as clescribed'above. Cu F UN3291, Regulated Medical Waste, n.o.s., S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone 6.2, PGII Cu F1 UN3291, Regulated Medical Waste, n.o.s., Applicable Permit Numbers: IE F3 -Wi 6.2, PGII jr, - INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Cu F1 UN3291, Regulated Medical Waste, n.o.s., Print/Type Name Signature Date et Uj 6.2, PGII a -L T oUMJ x Li Cu FI UN3291, Regulated Medical Waste, n.o.s., owa CL M cc. � INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. 6.2, PGII 71 Cu Ft UN3291, Regulated Medical Waste, n.o.s., Date 7. DISCREPANCY INDICATION 6.2, PGII -4 Cu Ft 8A. Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: Cu Ft 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately LS 10- ............ Cu Ft LE�- V ZEE -2 1771-- T C-) 9 described above by the proper shipping name, and are classified, packaged, marked and lab elled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations:' A Printedrryped Name :Signature Date IM 4. TRANSPORTER 1 ADDRESS: Phone LU Applicable Permit Numbers. 0 "7 (L a. Z TRANSPORTER: tERTIIFICATION:-Rec6i4of",ffteAi(�alwas1'e as clescribed'above. Print/Type Name -v '4ature Date S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone Lu loci !R cc Applicable Permit Numbers: IE F3 -Wi OWD G.MZ cricced: Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above Print/Type Name Signature Date et Uj 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: oUMJ x Li Applicable Permit Numbers: owa CL M cc. � INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. , Z x Print/Type Name Signature Date 7. DISCREPANCY INDICATION 8A. Designated Facility: 8B. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: LL �z Z g! Uj D -j Lu TREATMENT FACILITY: I certify that'l have been authorized by the applicable state agency to accept untreated medical wastes and that I have L received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LE�- V ZEE -2 1771-- T C-) 9