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%8? sterlicycle' <br />Protecting People. Reducing Risk: <br />I <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-806-424-9300 STANDARD MANIFEST 001 -10 -06 -STI <br />CUSTOM21132 <br />1. <br />Generator's Name, Address anWelephone Number <br />A a <br />1� 4 43 1 i A "1 14 <br />J, 4: 4 i - , <br />V t,4 <br />4 <br />77 <br />CUSTOMER NUMBER <br />GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUI <br />UN3291, Regulated Medical Waste, n.o.s., <br />CONTAINERS <br />6.2, PGII <br />J <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGI I <br />UN3291, Regulated Medical Waste, n.o.s, <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGlI <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />TOTALS 0 - <br />described above by the nmnpr qhinninri n;;mes nnrl ares nlnsQifi­l —k—H -1-4 —A <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations:' <br />XPrinted/TvDed Name Oinnntwa <br />Date <br />IX 4. TRANSPORTER 1 ADDRESS: Phone #: <br />U.1 <br />Applicable Permit Numbers: <br />as IL <br />(L Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name .� "qignature <br />-Date <br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: <br />LU <br />W'tRx Applicable Permit Numbers: <br />ow <br />0 LU <br />0.2Z <br />W CC < INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Zw= <br />PrinVType Name Signature Date <br />Uj 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />lZ �_ <br />LU <br />r3 W Applicable Permit Numbers: <br />Uj _j x <br />13 <br />0 2 <br />CL z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />US M <br />Z W <br />Print/Type Name Signature Date <br />1. Ulb(JHhI'ANUY INDICATION <br />8A. Designated Facility: E] 8B. Alternate Facility: ❑ 8C. Alternate Facility: ❑ 8D. Alternate Facility: <br />F - <br />HI�7 <br />LL <br />�V <br />Z <br />ul 1 -9 <br />7 <br />Uj <br />cc 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 />Print/Type Name Signature Date <br />LEAVE AT GENERATOR <br />