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<br />5�4rlcycle, IN CASE OF EMERGENCY CONTACT! CHEIVIvone �_onn,gon_oann
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<br />1. Generator's Name., Ad�dresp and Telep
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<br />CUSTOMER NUMBER
<br />GLJNEWATOR'b REGISTRATION )f
<br />2A. DESCRIPTION OF WASTE
<br />2B.
<br />CONTAINER TYPE
<br />2C. NO. OF
<br />2D. VOLUME
<br />UN3291, Regulated Medical Waste, n.es.,
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<br />UN8291, Regulated MWival Waste, n,os„.
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<br />UN3291, Regulated Nledlcal Waste, n.o,b„
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<br />3. Generator's CerWicatlon: °I hereby declare that the contents of this consignment arc fully and accurately TOTALS 10-
<br />described above by the proper ehlpping 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 />Printed/T ' ed Na me r-. ; ` °: _
<br />Yp Signature Date
<br />4, TRANSNONTI=R 1 ADDRESS: t.
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<br />Applicable Permit Numbers:
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<br />i z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />Print/Type Name Signature - A Data '
<br />6. INTERMEDIATE HANDLER 2 011ANSPORTER 2 ADDRESS: Phone !F:
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<br />Applicable Parmh Numbers:
<br />°G�tt INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wash, as described above.
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<br />,y 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone V);
<br />o Applicabiu Permit Numbers:
<br />Lu a INTERMEDIATE -HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wasle as described above, -
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<br />Printf Type Nam(, Signature Dale _
<br />Y. UtSGFiEFANCY INDICATION
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<br />TREATMENT FACILITY: I certify that I have been authorized by the applicable state agericy 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 />Printrrype Nam6 Slgnaturo Datu
<br />All
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