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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001.10 -06 -STD
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<br />CUSTOMER NUMBER „ GENERATOR'S REGISTRATION #
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<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 ® ..
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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.”
<br />Printed/Typed Name ,;.,���a �"� ��.�., Signature 1 _
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<br />Date '
<br />4. TRANSPORTER 1 ADDRESS:,f'ho
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<br />Applicable Permit Numbers.
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<br />TRANSPORTER CERTIFICATION.= Receipt of medical waste as described above.
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<br />Print/Type Namei f. -g �a°t" -{Signature I
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<br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS:
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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 />PrintfType Name Signature
<br />Date
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<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS:
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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 Name Signature
<br />Date
<br />7. DISCREPANCY INDICATION
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<br />E] 8A. Designated Facility: 8B. Alternate Facility: ® 8C. Alternate Facility:
<br />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
<br />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
<br />Date
<br />LEAVE AT GENERATOR
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