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<br />IN CASE OF EMERGENCY CONTACT: CHEMTREC 1.500 -424 -MOO STANDARD MANIFEST00 1-io-06-STI)
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<br />1. Generator's Name, Address and TelepfflKe Number
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<br />2A. DESCRIPTION OF WASTE
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<br />2C. NO. OF
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<br />3. Generator's Certification. 'I hereby cleciare that the contents at this consignment are fully and 60CL TOTALS Do,
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<br />described above by the proper shipping risme, and are classified, packaged, marked and labelled/placarded, p.
<br />are in all respects in proper -%o ndition for transport aoqqrdjpq to applipable international and national governipental,regulations'
<br />xV Printedrryped Name' —Sign 11 a . iurel
<br />Date
<br />4. TRANSPORTER I ADDRESS:
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<br />Applicable Permit Numbers:
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described abov
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<br />Date
<br />Print(Type Name o`�'/ Signature
<br />5. INTERMEDIATE HANDLER 2 TRANSPORTER 2 ADDRESS:
<br />Phone
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: RacGipi ol'medical wash) as described above.
<br />PrInt/1"ype Name Signature
<br />Date
<br />S. INTERMEDIATE HANDLER 9 /TRANSPORTER 5 ADDRESS!
<br />Phone #:
<br />Applicable Permit Numbars:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical WaStF.1 as described above,
<br />Print/Type Name Signature
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<br />7. DISCREPANCY INDICAI'ION
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<br />TREATMENT FACILITY: I certify that'll 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 />FrInt/Type Name Signature
<br />Date
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<br />8T/90 39Vd dVO N3AVHH-13 NOSGNIM ZZ90LLP60Z, TS:LT 7,TOZ/9T/80
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