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Stericycle IN CASE OF EMERGENCY CONTACT:CHBATREC 1-800-424-9300 STANDARD MANIFEST 001-10-06-STD
<br /> .Og People.Reducing Risk. i CU 10MER NO.21
<br /> 1.Generator's Name,Address and Tellephwe Number
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<br /> CUSTOMER NUMBER
<br /> 4 j GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C. NO.OF 2D. VOLUME
<br /> UN3291,Regulated Medical Waste,n.o.s., CONTAINERS
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<br /> *3.genera is Certification:110ation
<br /> -'1
<br /> hereby declare
<br /> re thatthe
<br /> contents
<br /> of
<br /> -s
<br /> consignment are fully and accurately
<br /> - TOTALS
<br /> Cu Ft.d.,bed a veby the proper shipping name,and are classified,
<br /> packaged,marked and labelled/placarded,
<br /> ar In al12re. tsn pr-p1d,tonf.rtratransport to international and national governntal re lations"
<br /> Pr,n d/Typed Name Sinaure
<br /> PORTER IADDR ADDRESS:
<br /> I Phone#:
<br /> Lu S1-7" 7, .3
<br /> I`- Applicable Permit Numbers:
<br /> IM 41.�5 41. Swi-ft Ave
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<br /> Z TRANSPORTE RTIFICATI eceipt of medical waste as describe daU8
<br /> ve.
<br /> Print/Type Name J Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone#:
<br /> :x 0: Applicable Permit Numbers:
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<br /> < INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> U 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> M
<br /> Applicable Permit Numbers:
<br /> z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 7.DISCREPANCY INDICATION
<br /> ;2446"Desiginated Facility: I 8B.Alternate Facility: ®8C.Alternate Facility: 8D.Alternate Facility:
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<br /> Stencycie, Inc. Stericycle,Inc. qtr
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<br /> 4135 VV Swift A N F;0),'bj,)rQ C), 1"11,��r — )rive.
<br /> Nortr;6all LaKe, 6-4 0'-`4 .'a +a,' t:A 09-1-02-'?.
<br /> TSj( ST22 3A-448--!A-3b TSi,()STRi VFD
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<br /> 'a- TREATMENT FACILITY: I c&#"atl have been authorized by the applicable state agency to accept untreated mec1APPjaae&Alffiat I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> Print/Type Name SignatureC'U E WILSON
<br /> 4-,
<br /> 4
<br /> fransterre ft to
<br /> ORiGINAL
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