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Sterlicycle,
<br />Protecting People. Reducing Risk.
<br />IN.CASE OF:EMERGENCY CONTACT: ..CHEMTREC.18qO,-4?4-9300 STANDARD MANIFEST 001 -10 -06 -STD
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<br />1. Generator's Name, Address and lepilMone Number. I 11, V ;,.q a 1 0
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<br />CUSTOMER NUMBER I GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />28. 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 TOTALS 0-
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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."
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<br />Date
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<br />4. TRANSPORTER I ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION Re' edicai waste as described above.
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<br />Print/Type Name Signature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />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 />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Date
<br />7. DISCREPANCY INDICATION
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<br />SA. Designated Facility: E] 8B. Alternate Facility: 8C. Alternate Facility:
<br />E] 8D. Alternate Facility:
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical 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
<br />Date
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