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W" zrerocycie 0.0W Protecting People. Reducing Risk. - IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD I— I lu a-vvt; ...UJUC�RjU wastes in accoraance with the requirement outlined in that authorization". I Print/Type Name Signature Date LEAVE 107, 'GEINERATOR i Generat&'s Name, Address and Telw6ne Number 'j, f �g I k y 1 4 t j 4� EV;vt V 'X "l L 7 CUSTOMER NUMBER GENERATOR'S REGISTRATION # 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s 6.2, PGII 7 - , . , -1— - 1 7 CONTAINERS UN3291, Regulated Medical Waste, n . s., 's, Cu 1 6.2, PGII Cr. UN3291, Regulated Medical Waste, n.o.s;; Cu 1 0 6.2, PGII UN3291, Regulated Medical Waste, ri.os.'-- Cu I 6.2, PGII W UN3291, Regulated Medical Waste, n.o.s., Cu F 6.2, PGII WZ UN3291. Regulated Medical Waste, n.o.s., Cu F 6.2, PGII UN3291, Regulated Medical Waste, n.o.s., Cu F 6.2, PGII UN3291, Regulated Medical Waste, n.o.s., Cu F 6.2, PGII Cu F Cu F 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accuratelyLO 0 - TA LS I described by I above the proper shipping name, and are classified, packaged, marked and labelled/placarded, and Cu F are in all respects in proper condition for transport according to applicable international and national governmental regulations." -- Printed/Typed Name Signature 4. TRANSPORTER 1 ADDRESS: Date cc LU Phone #:, 'V 7 Applica'bl'e Permit Numbers: < 0 [L Z 4 - TRANSPORTER CERTIFICATION. Receipt of medical waste as described above. Print/Type Name haiu—re Date 5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: C%i LU Phone Lu cc LU Applicable Permit,Numbers: 0 -- a Z ZLU W -x W INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date Lu 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Cr Phone #: L4 W 0 0 2 Applicable Permit Numbers: CL Z Rix < Uj INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Z x C � cc — I.- PrintlType Name Signature Date 7. DISCREPANCY INDICATION u IMF grg 8A. Designated Facility: ❑ 8B. Alternate Facility: ❑8C. Alternate Facility: ❑8D. Alternate Facility: LL Z 'j'9 UJ 6. r81 TREATMENT 8 FACILITY: I certify that I have been authorized by the awlicable state qripnr.v to nnni-nt tin .,q . . . I— I lu a-vvt; ...UJUC�RjU wastes in accoraance with the requirement outlined in that authorization". I Print/Type Name Signature Date LEAVE 107, 'GEINERATOR