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MEDICAL WASTE TRACKING FORM NUMBER
<br /> GF.O.ee Stericycle' CASE OF EMERGENCY CONTACT:CHEMTREC 1-800#300 STANDARD MANIFEST 001.10-06-STD
<br /> Protecting hople.Reducing Risk: t CUSTOMER NO.21132
<br /> 1.Generator's Name,Address and Telephone Number ji
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<br /> CUSTOMER NUMBERGENERATOR'SREGISTRATION
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<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINEIRTYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS 0,
<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:'
<br /> XPrinted/Typed Name Signature Date
<br /> Cr 4.TRANSPORTER 1 ADDRESS: Phone#:
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<br /> Applicable Permit Numbers:
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<br /> CL Z TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrintfType Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone
<br /> UJIffi Applicable Permit Numbers:
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<br /> ,uINTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br /> PrintlType Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
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<br /> III Applicable Permit Numbers;
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<br /> W= INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
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<br /> PrintlType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
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<br /> $A.Designated Facility: E]8B.Alternate Facility: 8C.Alternate Facility: E] BID.Alternate Facility:
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<br /> W -01TREATMENT 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/Type Name Signature Date
<br /> LEAVE AT GEMERATOR
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