Laserfiche WebLink
• Stericycle <br />o Protecting People. Reducing Risk. <br />tu9cvils?1L VVIIAO I G I M14%,milmu rurlivi IVUIvint: <br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD <br />COSTOMER NO. <br />1. Generator's Name, Address and Telephone Number 4, wtl, i <br />A i i <br />CUSTOMER NUMBER GENERATOR'S REGISTRATION # <br />2A. DESCRIPTION OF WASTE <br />2B• CONTAINER TYPE <br />2C. NO. OF <br />2D. VOLUME <br />UN3291, Regulated Medical Waste, n.o.s.,z» <br />_ <br />art_ ti <br />CONTAINERS <br />6.2, PGII <br />_ _ <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />. <br />6.2, PGII <br />Cu F <br />CC <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />= qe - - _ <br />® <br />-- <br />Cu F <br />Q <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />tll <br />UN3291, Regulated Medical Waste, n.o.s., <br />o <br />Z <br />6.2, PGII <br />m <br />UN3291, Regulated Medical Waste, n.o.s.,Cu <br />F <br />6.2, PGII <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />7a-71 H <br />Cu Ft <br />UN3291, Regulated Medical Waste, n.o.s., <br />w _ <br />6.2, PGII <br />Cu Ft <br />—[ <br />Cu Ft <br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately :TOTA LS <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and Cu Ft <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations" <br />Printed/Typed Name Signature < - ; : Date ' <br />4. TRANSPORTER 1 ADDRESS:CC Phone #:; ? - <br />W <br />� <br />_ <br />T _ ' �, r — Applicable Permit Numbers: <br />(- <br />_ <br />Cl) <br />a a <br />TRANSPORTER CERTIFICAT! ONc Receipt of medical waste as described above. <br />CC <br />~ <br />'' ' ";= J <br />Print/Type Name > m = e Signature h Date ;r a <br />, <br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #: <br />N W <br />ujaw <br />= Applicable Permit Numbers: <br />D <br />0WG <br />to < <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />a_Z <br />Print/Type Name Signature Date <br />F <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: <br />LU <br />a w <br />W <br />Applicable Permit Numbers: <br />w a <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />aw= <br />h <br />Print/a Name <br />T YP Signature Date <br />7. DISCREPANCY INDICATION <br />A� <br />u <br />QA. Designated Facility: <br />8B. Alternate Facility: <br />8C. Alternate Facility: <br />E] 8D. Alternate Facility: <br />..t m <br />LL <br />Z 13= <br />Lu <br />E a1 s "` , iV, i r"""L ►: i ceruly inat I nave oeen autnonzea Dy 1ne applicable state agency to accept untreated 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 <br />Signature <br />Date <br />