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y Stericycie" IN gASE OF EMERGENCY CONTACT CHEMTREC 1 800 424.9300 -STANDARD ryl NIFEST 001 -10 -06 -STD
<br />®® Protecting People. Reducing Risk. .. ... _ _.AOL
<br />a1 I rscHI IwCIV I I-wclu I T: 1 ceruty mat I nave oeen autnonzea by the applicable state agency to accept untreated medical wastes and that I have
<br />e ° received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT G7,:-E7-1A1TC,)Pi
<br />1. Generator's Name, Address and Tele hone Number t 4 I t 's t �'° t, i20 9 iA
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<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
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<br />CONTAINERS
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS "` Cu F1
<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 />YP Signature Date
<br />4. TRANSPORTER 1 ADDRESS:Phone #:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION:"Recelpt,pf medical waste as described above.
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<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
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<br />7. DISCREPANCY INDICATION
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<br />8A. Designated Facility:
<br />8B. Alternate Facility:
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<br />a1 I rscHI IwCIV I I-wclu I T: 1 ceruty mat I nave oeen autnonzea by the applicable state agency to accept untreated medical wastes and that I have
<br />e ° received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature Date
<br />LEAVE AT G7,:-E7-1A1TC,)Pi
<br />
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