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<0, n 15P Stecycle' Protecting People. Reducing Risk. evlLL ALMS- VVMQ I ZZ 1 nM%1r911V%J r%anivi Vitulvior-ri IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD CUSTOMER NO. 2& LEAVE AT GEHERATOR 1. Generator's Name, Address and Telephone Number I N f 4 CUSTOMER NUMBER GENERATOR'S REGISTRATION # 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s., 4 - :-f. L CONTAINERS 6.2, PGII Cu Ft. UN3291, Regulated Medical Waste, n.o.s.,7 6.2, PGII Cu Ft. CC UN3291 Regulated Medical Waste, n.o.s.,77 j 6.2, PGII Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 11 6.2, PGII Cu Ft. LLJ UN3291, Regulated Medical Waste, n.o.s., Z 6.2, PGII Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 6.2, PG I I Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII Cu Ft. Cu Ft. 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS0- Cu Ft. described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations." Printed/Typed Name Signature Date 4. TRANSPORTER 1 ADDRESS: Phone #: IJU Applicable Permit Numbers: CC 71 0 Z OC c. RZ TRANSPORTER CERTIFICATION Receipt of medical waste as described above. i IM / - I Print/Type Name Signature Date S. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS: Phone #: NW WM!R M Applicable Permit Numbers: ow rx W -j 0 Z 0 Z Zc: < LU INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: IC � 5 Uj s= Applicable Permit Numbers: 53 n0 x 2 Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. W < Z x Print/Type Name Signature Date 7. DISCREPANCY INDICATION 8A. Designated Facility: ❑ 8B. Alternate Facility: 0 8C. Alternate Facility: 8D. Alternate Facility: -5 F. 7 -979 tg! E U TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have C2 received the above indicated wastes in accordance with the requirement outlined in that authorization. Print/Type Name Signature Date LEAVE AT GEHERATOR