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•."=LJILAL WAts I r- I IlAt,&INLI rUrliVf 14URVIOC <br />Stericycle, 1� ­ - -STANDARD MANIFEST 001.10 -10 -06 -STD <br />INfja$E-QF EfflERGENCY CONTi��T�C�EMTREC�%1-.800-424-9300 <br />• Protecting People. Reducing Risk. <br />CUSTOMER NO. 20 <br />LEAVE AT GENERATOR <br />Address and Telephone Number *Ffiv',�4 1 3 11 <br />1 Generator's Na�mti <br />-3 <br />• ;Ul lit <br />a 2mH <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., <br />CONTAINERS <br />6.2, PGII <br />Cu Ft. <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2, PGO <br />Cu Ft. <br />CC <br />UN3291, Regulated Medical Waste, n.o.s., <br />06.2, <br />PGII <br />Cu Ft. <br />Regulated Medical Waste, n.o.s., <br />t7 7, <br />jrUN3291, <br />6.2, PGII <br />Cu Ft. <br />UJ <br />UN3291, Regulated Medical Waste, n.o.s., <br />Z <br />Z <br />6.2, PGII <br />Cu Ft. <br />F5 <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, 13(311 <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.s., <br />6.2, PGII <br />Cu Ft. <br />Cu Ft. <br />3. Generator's Certification -'9 hereby declare that the contents of this consignment are fully and accurately TOTALS <br />Culabelled/placarded, <br />described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, <br />are in all respects in proper condition for transport according to applicable international and national governmental regulations.' <br />22 <br />PrintedfTyped Name Signature <br />Date <br />4. TRANSPORTER 1 ADDRESS: <br />Phone <br />UJI <br />A 7 ...... <br />Applicable Permit Numbers! <br />0 <br />CL <br />cn <br />CL < Z <br />TRANSPORTER CERTIFICATION Receipt of medica-'l waste as described above,• <br />IM <br />2,/ Y <br />Print(Type Name Signature <br />Date <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: <br />Phone #: <br />j CC <br />Applicable Permit Numbers: <br />5 _ <br />LUD <br />,1=WJ <br />umi �x <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature <br />Date <br />uj <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />:j Q CC <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />5MZ <br />Print/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />F1 8A. Designated Facility: E] 813. Alternate Facility: F1 8C. Alternate Facility: ❑ 8D. Alternate Facility: <br />3 1 <br />3 <br />0 <br />8 <br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical <br />wastes and that I have <br />ij <br />received the above indicated wastes in accordance with the requirement outlined in that authorization. <br />i <br />Print/Type Name Signature Date <br />LEAVE AT GENERATOR <br />