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<br />Sterlcycle` IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
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<br />1. Generator's Name Address and Telefflffne Number e rr t' $ 11
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<br />CUSTOMER NUMBER
<br />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.,CONTAINERS
<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 />Print/Type a Name
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<br />7. DISCREPANCY INDICATION
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately
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<br />described above by tha nrnnesr chinninn names anri ares H...irinri —L--i.,,��4oa � 4 ISP o11 .4i.,i�,.�.a.,.r .,..a
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<br />are in all respects in proper condition for transport according to applicable international and national governmental regulations.
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<br />IM 4. TRANSPORTER 1 ADDRESS:
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<br />CL q TRANSPORTER CERTIFICATION Receipt , f medical waste as described above.
<br />Print/Type Name art l �� w�' ` Signature -
<br />Date
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<br />Applicable Permit Numbers.
<br />Date
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<br />HANDLER5. INTERMEDIATE 2 TRANSPORTER 2 ADDRESS: Phone #:
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<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #:
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<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 />Print/Type a Name
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<br />7. DISCREPANCY INDICATION
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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 Date
<br />LEAVE AT GENERATOR
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