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1`9Stericycle IN USE OF EMERGENCY CONTACT: n*smrnsc1-8o0-4u«-9xoo STANDARD MANIFEST 001 -10 -06 -STD <br />-------'-'---'—�--'----' <br />Protecting People. Reducing Risk. <br />' <br />1. Generator's Name, Address and Telephone Number V� <br />jv <br />CUSTOMER NUMBER <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINERTYPE <br />2C. NO. OF, <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />JIM <br />Cu Ft. <br />F3 <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu Ft. <br />UN3291, Regulated Medical Waste, ri.o.s., <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ;T <br />Cu Ft. <br />described above by the proper shipping name, and are classified, packaged, marked and labellecl/placarded, <br />are in all respects in proper condition for transport according to a pplicable international and national governmental regulations . <br />Printed[Typed Name Signature Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone#: <br />Applicable Permit Numbers: <br />Z <br />TRANSPORTER dERTIFICA:hON1:_0'66eIp_t"­8f medical waste as described above. <br />Print(Type Nam' 6griature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />ru!R <br />Applicable Permit Numbers: <br />8 LU <br />3.50 <br />Uj <br />2 - � <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print(Type Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />,ru Cr <br />5 U.1 <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />,,,z <br />r UJ <br />Print/Type Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />0- <br />= <br />8A. Designated Facility: E] 88. Alternate Facility: <br />1'�_ El 8C. Alternate Facility: <br />8D. Alternate Facility: <br />u <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />PrintfType Name Signature <br />Date <br />' <br />