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<br />®® Protecting People. Reducing RiA
<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
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<br />x aII - MCIA..11CIN' rA ,'L' I r: I cerury mai I nave been autnorizea 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
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<br />Date
<br />.'Generator's Name, Address and Telep ne Number
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<br />CUSTOMER NUMBER GENERATOR'S REGISTRATION #
<br />2A. DESCRIPTION OF WASTE
<br />2B- 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 ® 7` Cu Ft.
<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.'
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<br />4. TRANSPORTER 1 ADDRESS: Phone #:,
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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 />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #:
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<br />7. DISCREPANCY INDICATION
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<br />10A. Designated Facility:
<br />E 8B Alternate Facility:
<br />8C. Alternate Facility:
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<br />x aII - MCIA..11CIN' rA ,'L' I r: I cerury mai I nave been autnorizea by the applicable state agency to accept untreated medical wastes and that I have
<br />I
<br />received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Print/Type Name Signature
<br />LE WE AT GENERATOR
<br />Date
<br />
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