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®®® , sterlcycle' IN CASE OF EMERGENCY CONTACT: CHER"Tour <br />' ®® Prmaakyf PwPIu..duchw P&W ; '� i' F,I — :':✓ INN <br />Z o <br />1. Generator's Name, <br />Address and 7®Irrph n® Number - <br />Z, CARE <br />i <br />UN3291, Regulated Medical Waste, n,o.s <br />mcvrvML. vvrour` Illf\N�\II\VI I VrlWl ra►+rxn►+�. <br />STANDD MANIFEST 001 -10 -0E -STD <br />ZIOZ 'Ll TnVj.- lit Pani23a� <br />a:' it :9.'2 <br />2C. NO. OF 2D. VOLUME <br />CONTAINERS <br />Ct <br />I'`1'Y ee ':it i7 ::k'.• (,g,T:.� 1-`• ar:Y tks it :: 2:r;°; CU I <br />s. Generator's Certification; "I hereby declare that the contents of this consigr.pent are fully and accurately TOTALS ® Cu I <br />described above by the proper shipping name, and are classltled, 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/Typed Name Signature Date <br />x , I <br />4. TRANSPORTER t ADDRESS' a Phone tf; "°'•I J <• + •'' - •' — <br />�- .u: <br />?Yf:.w":•" :i.i:"�4,�7:'3.d;• .�.i9d' .5��'.t�Xl : .�"i.l`S� .�i611:.'<:i4i�r.�$:i Cyt."5�:::lturc�67t'I: <br />YAM . � `6 N1:� «t Vit• ' Applicable Permit Numbers: <br />IL <br />Wr!`• . <br />cL TRANSPORTE CEFIT'IFICATION: IReoelpt of medical waste as i ,g,.cnbed above.. <br />Priril/fype Name 1 Slgnatupo' ' Date �M _ <br />S. INTERPAEDIA11 1�ANDL R 2 / TR N_ SPORTEIR 2 ADDRESS: Phone 8; <br />vs� Applicable Permit Numbers; <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical wast, as described above. <br />Print(Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 / TRANSPORTE.R 3 ADDRESS: Phone 11; <br />c w Applicable Permit Numbers: <br />W .b <br />EINTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waste as described above, <br />T <br />Print/Type Name Signature _ Date <br />CUsTOrvign Nula®ER (K,18 0 e, S ei�, M'[P3 1, <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />;.TREATMENT FACILITY: I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />:eived the above indicated wastes In accordance with the requirement outlined In that authorization, <br />Print/Type Name Signature Date <br />M i-X0fir. Aqr-"aW"xhr^rr <br />8T/L0 39dd dd0 N3AVHW-13 dOSQNIM <br />ZZSOLLb60Z TS:LT ZT07,/9T/80 <br />