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�.c <br />Z,c <br />,!e- <br />JI.J.6,Q utak: <br />IN CASE OF EMERGENCY CONTACT! CHEMTRFr 11 -PM - <br />..n _ yM. 3,4. - Z clZNO IN <br />I tManaratnrIn Name- AdeirAq-, and Telenh Number <br />IIANDARD MANIFEST oc9-10-06-STD <br />10 'Ll '2 n V, W I . J .. .. P A I ; 0 <br />8T/EO 39Vd <br />NVO N3AVHW-13 NOSGNIM <br />ZZSOLLV60Z TS:LT ZTOZ/9T/80 <br />r .! �l q q , <br />V Q <br />p <br />-0, Gswowows Re2aig'MATION # <br />CL15TOMell NUM89H 6F,-` -0 <br />ZA. DESCRIPTION OF WASTE <br />2B. CONTAINER TYPE <br />2C. NO, OF <br />21). VOLUME <br />UN3291 Regulated Medical Waste, n.a,s, <br />CONTAINERS <br />62'PGli <br />4,12 1.�Q <br />Cu F <br />UN3291 Regulated Medical Waste, n.o.B., <br />6,2, PGII <br />3 Tkw`,Y <br />Cu F <br />pG <br />UN3291 Regulated Medical Waste, mox,, <br />I <br />44 S S co <br />_T <br />6,2. PGI <br />. <br />Cu F <br />UN3291. Regulated Modica[ Waslo, n.u.s., <br />gay 1' z <br />6.2. PG11 <br />Cu F <br />LLI <br />Z <br />UN3291Regulated Medical Wasla, <br />6.21 PC I I <br />2 1 <br />Cu F <br />W <br />UN3291, Regulated Medical Waste, n,o,s,, <br />62, PO 11 <br />Cu F <br />UN3291, Rogulated w1calcal Waste, <br />62, PGII <br />Cu F <br />UN3291 Regulated Medical Waste, mo.s., <br />6.2, PG11 <br />Cu F <br />Cu F <br />3. Generator's Certification- "I hereby declare that the contents of this consIgnment are fully and accurately TOTALS'Cu <br />F <br />described above by the proper/ hipping name, and are classified, packaged, marked and laballOdp—Q, <br />are In all respects- in proper c qition for transport coj�d�inR to H'pplicablO international and national govt)rn W4-regulallon$.' <br />4 i-.............. I..,-­ <br />k,A <br />x <br />Printed/Typed Name 819 alu <br />Date <br />CTRANSPORTER 1 ADDRr.-SS: <br />Phone 4: SA 7 5 U:2 <br />a51 <br />Permit Nu ors: <br />Applicable Pe rrib <br />L <br />TRANSPORTER CERTIFICATION: Rocolpl of medical waste as described above. l r' <br />d A— <br />Print/Type Name Signature <br />Date <br />S_ INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS: <br />Phone <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PdnYType Name Signature <br />Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: <br />Phone #: <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />PrinV'Iype Name Signature <br />Date. <br />7. DISCREPANCY INDICATION <br />Tr-arlsi�tlred zt� Clio _­ WoM Salt Laka., UT <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />94E <br />TR ATMENT 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 />PrInv'rype Name Signature <br />Date <br />8T/EO 39Vd <br />NVO N3AVHW-13 NOSGNIM <br />ZZSOLLV60Z TS:LT ZTOZ/9T/80 <br />