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Stericycle- <br />• Protecting People. Reducing Risk. <br />IN CASE OF EMERGENCY CONTACT: Cl - <br />Generator's Name, Address and Telep on <br />L <br />Number <br />MVlr-LJI%-AL WAZi I t I HAUKINtj I-UHM NUMBS <br />STANDARD MANIFEST 001 -10 -06 -STD <br />CUSTOMER NUMBER <br />GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO, OF 2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s., T, I I- CONTAINERS <br />6.2, PGII <br />UN3291, Regulated Medical Waste, ri.o.s.,Cu F <br />6.2, PGII T 1_` <br />UN3291, Regulated Medical Waste, n.o,s.,Cu F <br />6.2, PGII Cu <br />UN3291, Regulated Medical Waste, n.o.s., — 7 <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., —Cu F <br />6.2, PGII <br />UN3291, Regulated Medical Waste, n.o.s., Cu F <br />6.2, PGII <br />uk <br />UN3291, Regulated Medical Waste, n.o.s., Cu F <br />6.2, PGII <br />CU F <br />UN3291, <br />Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />Cu Fi <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, <br />Cu Fj <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br />XPrinted/Typed Name tSignature <br />4. TRANSPORTER I ADDRESS: <br />-Date <br />Phone # <br />IM <br />U.1 <br />Applicable Permit Numbers: <br />< 0 <br />7, <br />(L Z <br />TRANSPORTER CERTIFICATION Receipt <br />I o , f' medical waste as described above. <br />PrintlType Name Signature <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Date <br />Phone #: <br />CM Uj <br />HM!R , <br />L4 <br />Applicable Permit Numbers: <br />Zcnx< <br />Uj <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />Uj <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />I- <br />W it <br />�Bw <br />UJ -J <br />Applicable Permit Numbers: <br />0 <br />z <br />Ul <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Z <br />< I.- <br />PrintfType Name Signature <br />Date <br />7. DISCREPANCY INDICATION <br />71 <br />08A. Designated Facility: ❑ 8B. Alternate Facility:❑8C. Alternate Facility: <br />=80. Alternate Facility: <br />-j <br />LL <br />Z I <br />;7 <br />Lu 79 <br />711 <br />7 <br />.0 <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 />