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<br />IN CASE.OF EMERGENCY CONI T. CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD
<br />CUSTOMER NO.,
<br />98 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />A received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Printrrype Name
<br />Signature
<br />LEAVE AT GENERATOR
<br />Date
<br />1. Generator's Name, Address and Telep ne Number IIS 114 Ns INW11 11 1 3 Ut S 4 1t£ 1 N,t 71 i5 , # ail, 3,`.
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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 �,.' "' A • `' 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 />7. DISCREPANCY INDICATION
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<br />8B. Alternate Facility:
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<br />98 TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br />A received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br />Printrrype Name
<br />Signature
<br />LEAVE AT GENERATOR
<br />Date
<br />
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