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tericycle, decting People. Reducing Risk. merator's Name, Address and IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 CUSTOMER NO 31eplWe Number �3 WER NUMBER GENERATOR's REGISTRATION III STANDARD MANIFEST 001 -10 -06 -STD i t, -11, V I` I I If121 IBM 111 :SCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME Regulated Medical Waste, n.o.s., CONTAINERS ti. -n 4 4 3a, Cu Ft. Regulated Medical Waste, n.o.s., Cu Ft. Regulated Medical Waste, n.o.s., II 1? Cu Ft. Regulated Medical Waste, n.o.s., Cu Ft. Regulated MediVI Waste, n.o.s., Cu Ft. Regulated Medical Waste, n.o.s., Cu Ft. Regulated Medical Waste, n.o.s., Cu Ft. Regulated Medical Waste, n.o.s., Cu Ft. I Cu Ft. nerator's Certification: "I hereby declare that the contents of this consignment are fully and accurately MPH ninn— by the n—nor ehinninn n— —i ire A—M-4 —L—A—1 —�-4 —A TOTALS 0- Cu Ft. all respects in proper condition for transport according to applicable international. and national governmental regulations.' Name Date NSPORTER 1 ADDRESS: v Phone #: Applica'6fe Permit Numbers:" ISPORTER, CERTIFICATION:, Receipt of waste as described above. pe Name Signature Date RMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: Applicable Permit Numbers: IMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. pe Name , Signature Date RMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: Applicable Permit Numbers: [MEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. )a Name Signature Date REPANCY INDICATION lesignated Facility: Lj 8B. Alternate Facility: 8C. Alternate Facility: ❑ 8D. Alternate Facility: —D "IENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have above indicated wastes in accordance with the requirement outlined in that authorization. Signature Date ti LEAVE AT GENERATOR