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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 />1. Generator's Name, Address and Teleffim
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<br />GENERATOR'S REGISTRATION #
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<br />2A. DESCRIPTION OF WASTE
<br />2B. CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.o.s.,
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br />Applicable Permit Numbers:
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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 />are in all respects in proper condition for transport according to applicable international and national governmental regulations.,
<br />APrinted/Typed Name Signature Date
<br />4. TRANSPORTER 1 ADDRESS: Rhone #:
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<br />7. DISCREPANCY INDICATION
<br />SA. Designated Facility:
<br />8B. Alternate Facility:
<br />8C. Alternate Facility:
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<br />8D. Altemate Facility:
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<br />7. DISCREPANCY INDICATION
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<br />8B. Alternate Facility:
<br />8C. Alternate Facility:
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<br />8D. Altemate Facility:
<br />LEA V E A G E �H E R ATO R
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