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rix uaEC/ i IMC MAY-Lh-LU11 (WhD) 15: 35 P. 036 <br /> 05/25/2011 WED 15154 FAX ®036/049 <br /> 1111r►.0 Stericycle' IN CASE OF EMERGENCY CONTACT;CHEMTREC t'-En�-T1�'3111f!' SrANDAAD MANIFEST 001.10.06•STo <br /> �• ..al..q hov,.benwr ryr• <br /> n��tc :2 Y grit,. is:~ "4J t.DP'--'.I'.1=I1=OX <br /> 1.Generator's Natne,Address and Telephone Numbe111 fill IN I IIIr <br /> ,-'fir: Lr✓D1 19 10A1 A t�L'S T T I <br /> 11 1 <br /> 575 3i.UTH <br /> 9 w:2�C. ; <br /> 'IC. t <br /> Cusmmrm alumum '.', ;C1"1 G1 MA&TOR's REGISt'RAnok 0 <br /> 2A.DESCRIPTION OF WASTE 28. CONTAINER TYPE 2C. NO.OF 20. VOLUME <br /> UN3291.Regulate*Medirel Waste.nAs CaNTAtTRS <br /> 6.2,PGII !TM-Me, KP.F5 - £ia;',"tcTn- sharps Traats Cart (59 ea :t) L <br /> UN3291RM0100 Medical Waste.n.o. <br /> 6.2.PGII ;" i:..,_. - ie�:•°yr�a rr:r.e:•os_ ysX :.. :ta Etr <br /> UN3291Regulated Medical Waste.n.o.s., <br /> 62.PGfi <br /> UN3291,Regulaled Medical Waste,n,o.s., <br /> 6.2.PGII <br /> I UN3291,Requtated Medttal LYastc n.e.s., <br /> 6.2,PGII <br /> U""' Regulated Regulated Medical Waste.n.os.. <br /> 6.2.PGli <br /> Utr13291,Regulated Medical Waste,n.os.. <br /> 6.2.PGII <br /> UN3291,Regulated Medical WSSte.n.o s., <br /> 6.2.PGII <br /> I <br /> 3.Generatar'a CerHiicetlon.-1 hareby declare that me contents of thus corrsigrimenl are Wily and accurately TOTALS 0-described above by the proper stripping name.and are elessHieid,packaged,marked and Iabened/placartfed,and 5 � <br /> are in all respects In proper condition for transport 6CCOMIng to applicable Inlernational and rlatienal governmen t gu g' <br /> Xi1PdrMe&Typed Name Signature Date •�G 3 I!1 <br /> }: 4.TRANSPORTER 1 ADDRESS; phone-it; <br /> rY <br /> Applfcabt <br /> t':7°• White 1 T e �• L_ 3 e Permit Numbers: <br /> q TRANSPORTER-CERTIFICATiO :'Recelpt Irr+ne waste as described above. <br /> z <br /> PrintlType Name Signeltrra Date 7` <br /> S.INTERMEDIATE HANDLER 21 TRANSPORTER 2 ADDRESS: Phone p: <br /> Appkablo hermit Number8: <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above. <br /> PrinVType Name %gnanue Date <br /> 6.INTERMEDIATE HANDLER 31 TRANSPORTER 3 ADDRESS: PhWW 0: <br /> s <br /> "I Applicable P;ermil Numbers: <br /> INTERMEDIATE HANDLER f TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> Print/Type Namo Slonature Date <br /> 7.DISCREPANCY INDICATION ) <br /> !I'?FI�i$fT?fi �O t-en-airiscz. I7,+c, <br /> i ❑6A.Dasignatod Faeolry; aB.Agomate Fedlrty: BC,Alremate Faclflry; 091Ttlem3te Fedllly: <br /> F::'tt:Lc II`JI�. '.!rrsl�.Y'sir�•;',� ;�i->Yi� tz;.; " zI3. -LIgr,l,e,lan; ', csitE,.. 41?rVY.�'.,�i:+aitdll tiL't'1:rt1:i .UL, <br /> i¢ S_., rrfsftu. 5 �.. rl7ih or:I Ity �_ <br /> rS;G� •:- i7t r`Sd�:l5 L�W� s f51]i?93 1355 N11�,- [! ) <br /> T= •i•�iIJ:aT23 4�..1��_�ti• r�;l�eq 1/1,':LGt.15'i:'ks:i �'rS;Y{'a�i n r a.j 7 z <br /> tg TREATMENT FACILITY: I certify that I have been Buthorixed by the applicabt ate a y o a p�treated m� /,,aslesaand Iha1 I have <br /> received the above indt ted ales in accordance with the requirernluo ,ned int Hon. <br /> Printftype Name* F �i�R Signature r D$ie � <br /> 1�s <br /> .,tea•,-. ... , <br />