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Stericycle' IN CASEOFEMERGENCY CON' <br />Proteaing People, Reducing Risk: <br />1 Generator's Name, Address and Tele one Number <br />XT:-CHEMTREC 1-200-424-9300 -,.—S-TANDARD MANIFEST 001 -10 -06 -STD <br />CUSTOMER NUMBER <br />_1 - 2 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., <br />TD 1j <br />CONTAINERS <br />6.2, PGII <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />UN3291 Regulated Medical Waste, n.o.s., <br />--f <br />6.2, PG1i <br />--- ----- <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu F <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu P <br />UN3291, Regulated Medical Waste, n.a.s., <br />6.2, PGII <br />Cu F1 <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft <br />`7 <br />Cu Ft <br />3. Generator's Certification: 1 hereby declare that the contents of this consignment are fully and accurately <br />TOTALS No - <br />1 <br />described above by the nronpr qhinninn names and aroclneeifi.H I—Le—,q -L-4 -4 <br />Cu Ft <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations:' <br />X Printed/Typed Name j j�-f C. <br />Signature -Date <br />4. TRANSPORTER I ADDRESS: <br />Phone <br />W <br />Applicable Permit Numbers: <br />tx <br />C 0 <br />7_ <br />CL Z TRANSPORTER CERTIFICATION :'Rec'eip-t of medical waste as described above <br />Print/Type Name Signature Date <br />— 5. INTERMEDIATE r—RIVIEDIAl E_ HANDLER 2 / TRANSPORTER 2 ADDRESS: r Phone <br />NW <br />M a = Applicable Permit Numbers: <br />5 Uj <br />ow20 <br />-1 <br />0. <br />Z <br />'n cc Z <br />UJ < INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print(Type Name Signature Date <br />5. IN I LHIVIEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />cc <br />W <br />Q INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />x <br />Print/Type Name Signature <br />7. DISCREPANCY INDICATION "T <br />LL 52 <br />)A. Designated Facility: <br />_j 8B. Alternate Facility: <br />C. Alternate Facility: <br />7 <br />Phone #: <br />Applicable Permit Numbers: <br />Date <br />8D. Alternate Facility: <br />TREATMENT FACILITY: I certify that I have been authorized by the 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/TvDe Name -vi—b— ­_ <br />LEAVE AT GENERATOR <br />