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00 Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 <br />Protecting People. Reducing itisk.' il-- <br />2 <br />1, Generator's Name, Address and Teleowe Number <br />jis, <br />X <br />Ll <br />Z <br />3 <br />CUSTOMER NUMBER <br />GENERATOR,s REGISTRATION # <br />STANDARD MANIFEST 001 -10 -06 -STD <br />4 <br />k k 13 s,i I 1A �Slln 41 <br />2A. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., <br />T <br />'I <br />CONTAINERS <br />Z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />6.2. PGII <br />T, I n T I 7 7Z <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />i <br />wApplicable Permit Numbers: <br />Z <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />Print/Type Name Signature Date <br />6.2, PGII <br />7 2 <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />a" <br />93 <br />J� <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />J <br />6.2, PGII <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 />Cu Ft. <br />UN3291, Regulated Medical Taste, n.o.s., <br />Print/Type Name Signature Date <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII _ <br />� .- - I % -_ _ <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII7? <br />Z <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />LS 11111 <br />Cu Ft. <br />dnqrrihpd nhnvp by tho nrnn.r Qhinninn name nnq nr. I ... ifi.,4 -L--4 -L-4 -4 <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations:' <br />_.X Printed/Typed Name Signature <br />4. TRANSPORTER 1 ADDRESS: <br />TRANSPORTER CERTIFICATION.-, Reieint of aiedi6al-waste as described above <br />Date <br />Phone, #: <br />f Applicable Permit NUmbers: <br />Print/Type Name Signature Date <br />LEAVE AT GENERATOR <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: <br />C cc <br />Applicable Permit Numbers: <br />H <br />Z <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />i <br />wApplicable Permit Numbers: <br />Z <br />7� <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />9r <br />8A. Designated Facility: � 86. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: <br />93 <br />J <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 />Print/Type Name Signature Date <br />LEAVE AT GENERATOR <br />