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d Stericycle' IN CASE OF EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 STANDARD MANIFEST 001 -10 -06 -STD Protecting People. Reducing Risk.' I . t 1; -, CUSTOMER NO. 21& 7" 1. Generator's Name, Address and TeIeP?We Number. �0 7 CUSTOMER NUMBER Ll'- I I GENERATOR'S REGISTRATION # q 3.1 q q 3 jaq 4�,j RIA, 2A. DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO. OF 2D. VOLUME UN3291, Regulated Medical Waste, n.o.s., Date CONTAINERS 4. TRANSPORTER 1 ADDRESS: 6.2, PGII Cu Ft. UN3291, Regulated Medical Waste, n.o.s., r 6.2, PGII cn Z Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 6.2, PGII Print/Type Name Signature Date '5 Cu Ft. UN3291, Regulated Medical Waste, n.o.s., Phone #: 6.2, PGII yo Cu Ft. 1.11\13pl, Regulated Medical Waste, n.o.s.,6.21 INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Gil Cu Ft. UN3291, Regulated Medical Waste, n.o.s., AJ 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: 6.2, 131311 Applicable Permit Numbers: Cu Ft. UN3291, Regulated Medical Waste, n.o.s., x 6.2, PGII Print/Type Name Signature Cu Ft. UN3291, Regulated Medical Waste, n.o.s., 7. DISCREPANCY INDICATION 6.2, PGII Cu Ft. J iq Cu Ft. 3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately A---AK-4 -k— k , k— — — �k; ;_ ---- — — ..I......3 -1 --- --.1 —1 —1 --A TOTALS I,. Cu Ft. LEAVE AT GENERATOR are in all respects in proper condition for transport according to applicable international and national governmental regulations." x Printed/Typed Name Signature Date 4. TRANSPORTER 1 ADDRESS: Phone Applicable Permit Numbers: cr7 0 r V f cn Z TRANSPORTER CERTIFICATION Receipt of fficidical waste as described above. Print/Type Name Signature Date '5 5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: Phone #: Applicable Permit Numbers: yo Z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. Print/Type Name Signature Date AJ 6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone #: Applicable Permit Numbers: ju 20 z INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. x Print/Type Name Signature Date 7. DISCREPANCY INDICATION 8A. Designated Facility: 8B. Alternate Facility: Ej 8C. Alternate Facility: E] 8D. Alternate Facility: j TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have received the above indicated wastes in accordance with the requirement outlined in that authorization. PrinttType Name Signature Date LEAVE AT GENERATOR