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%0 9 Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />P,jtecfing People. Reducing Risk.* <br />CUSTOMERNO. 21132 <br />"... <br />Generator's Name, Address and TeApne Number <br />7w- <br />1 It 3 1 117 7i s 11 "T I F N I N� I 111,9,1311 11113"1 <br />&4i.3 A V. d <br />E 4 11 MAI 21 <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <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 />CONTAINERS <br />6.2, PGII <br />� 14 - <br />CuF <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />IMLIN3291, <br />Regulated Medical Waste, n.o.s., <br />CuF <br />0 <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />CuF <br />Cr <br />6.2, PGII <br />W <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu F <br />Z <br />6.2, PGII <br />uJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu F', <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s.,Cu <br />2 <br />FI <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., <br />Cu Fi <br />6.2, PGII <br />Cu FI <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and <br />Cu Ft <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations:' <br />Printed/Typed Name Signature Date <br />4. TRANSPORTER I ADDRESS: Phone #: <br />cc <br />LLI <br />Applicable Permit Numbers:' <br />< 0 <br />2N 0. <br />j <br />Z <br />TRANSPORTER CERTIFICATION: Receipt of -medical waste as described above. <br />Print/Type NameDate <br />Signature <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone <br />cli <br />Applicable Permit Numbers: <br />0 UJI C3 <br />(5 .4 <br />ZIL IUM 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 />o <br />UJ <br />Applicable Permit Numbers: <br />N50 <br />cc Q INTERMEDIATE <br />HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z I- X <br />9Z <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />8A. Designated Facility: E] 8B. Alternate Facility: Lj 8C. Alternate Facility: ❑ 8D. Alternate Facility: <br />7j <br />B <br />Z NNm. <br />UJ g <br />TREATMENT <br />FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />received <br />the above indicated wastes in accordance with the requirement outlined in that authorization. <br />Print/Type <br />Name Signature Date <br />LEAVE AT GENERATOR <br />