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Rx llate/'rime MAY-25-2011 (WED) 15: 35 P- 037 <br /> 05/25/2011 NED 15: 54 FAX 2037/049 <br /> 6,+• 5toricyde' IN CASE OF EMERGENCY CONTACT;CKJEMTREC STANDARD MANIFEST 001•I04)6•STD <br /> =•u:e � 5?� - 4ti1)L-4 Z-1"ST;j .14D Rl',rt1 D._14 <br /> Z.Generator's Name,Address and Telephone Number 11 ill <br /> �I I i I f"i it D $ E E ill <br /> 1.1 Ili <br /> I Ill 111111,11 <br /> GIr�/1..f.)_I8�1~s''S4?3tii.-',i' H0,3 T';�L <br /> LO%•s , <br /> G�. cl--.'4 rj <br /> CUSTOMER NUMBER -r 9 •. GeRFRAXON'S REGISTRATION 8 <br /> 2A.DESCRIPTION OF WASTE- - 20: CONTAINER TYPE 2c. NO,OF 213. VOLUME. <br /> UN3291.Regulalt:o M*Wul Waste.ftos.. CONTAtNE19S <br /> 62.PGII tart;.=.► t:rc9 [fItGS - SiaSaste= ShaCns Tranz- Cart (59 ce ft) <br /> UN3291Regutaled Medkal Waste,r1o_s... <br /> � tte� �r._c• Ce: <br /> UN329t1Regulated MedicaIWasie,n.o.s.,62. 9 :C) <br /> UN3291,Regulated Medical 1Yaslt,n,OS.. <br /> 6.2.t'GII <br /> Uhf3291,Regulated Medical Wade.n.o.s.. <br /> 62.PGh <br /> 6 2 P 1GII <br /> 62. ,Regulated Medical Waste,n.o.s.. <br /> . <br /> S <br /> tIN3291,Reguialed Med'scai WaSTe.a.0.8„ <br /> 6.2.PGII <br /> tJN329t,Re1)uia,ed Medttal Waste.n.o.S-. <br /> 6.2.PGII <br /> ( <br /> r 5T <br /> 3.Generator's Certtllcattan;*1 hereby declare that the contents of this Consignment are fully and accurately OTALS I/ <br /> deSWibed above by the proper shipping name,and aro Classitied,packaged,marked and labetledlplacarded and <br /> are in all respects in proper eonddian for transport accordtn to appkaNe tniernational and nitaonai goverriyonlal regulations' <br /> Prins ped Name -Signa e Dats , <br /> r CTRANSPORTER I ADDRESS! Phone 0: <br /> at 1•:F% cis <br /> E Applic96ta'Pvrmlt Ntirtrhers:" <br /> xTcFTC'/L"La _ ~ Lf ` hi-2 _a a 7;,roaji: x:11 i:Ci <br /> TRANSPORTER FIi GATION•;Aacpl W Irsadl01 waste as described above. <br /> F <br /> PdnUType NameFAAff"rx Signature Data�LL-(O •[0 <br /> S.INTERMEDIATE HANDLER 2 1 TRANSP50ATER 2 AD SS: pyo M: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of rrtedicat waste as described above. <br /> Prird/Typa Name Signature Date <br /> 5.iNTERMEDIATE HAP40LER 3 r TRANSPORTER 3 ADDRESS: Phone It: <br /> Applicable Permit Numbers: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical Waste as described above. <br /> r <br /> Prirll/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> j I r'arlbewrt CCi r.�l�rt:':, `� :li fC tC Workh grail <br /> 1114T.Y- <br /> ;I Cj 8A,Dgsignntod F*c t , t16.AntmCne FeCltaty: 8C.Ahrxnat� . ttenTafe Faculty: <br /> :YsXZ.Ii9G. -II Yr^1A E IC n4�]���`±�al-:YI-1 E IN <br /> � � !it )�`_• .�.ry1:�='J�.r__ ���Cr'►1"i 11 5 � Q UftliGi= :_rT!rT RALc'oird.s�t x°'1371 FTiE5rtt7 CA, 63-12, id_r.1� �`i Leh?,JT���� YU, Or.,t,A. <br /> (Sol)*w_1 ^F�•al <br /> r{-N." S6• S755 <br /> tD13S r•', 1.ar�/Ln,;yngcnli C 1� ,I�-:i3 <br /> TREATMENT FACILITY: I certify that t have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br /> received the above indicate"d wastes in accordance with the requirement ouillned in that-auth6rizati0n. <br /> l PO Type Name Tp�� Signature f`'' �, ; %•r'r.~�• Date <br /> - r�orr_1Z.3A1 ' <br />