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stericycle, <br />IN CASE OF <br />EMERGENCY CONTACT: CHEMTREC 1400424 <br />Uti (zNO <br />'ONINIM <br />1. Generator's Name, Address and TelepMne <br />Number <br />STANDARD MANIFEST001-10-06-STO <br />L 6 1 0 6 11 'S n Vr,. di j' ff'A I ; D <br />gl Itll�!IH!��IIlR��lRi1�l�;i�l�1 <br />I FAVF AT 1f-.F:Mfl:D.KTnQ <br />8T/80 39Vd NVO N3AVHW-13 NOSGNIM ZZSOLLP60Z <br />TS:LT ZTOZ/9T/80 <br />CusvomaR Nuropeq 0 7+ .11 � 4! i, GENERATOFII6 ReGISTRAMON # <br />2A. DESCRIPTION OF WASTE <br />28. CONTAINERTYPE <br />2C. NO. OF <br />20. VOLUME <br />UN3291. Regulated Medical Waste, n.c.s., <br />16. <br />CONTAINERS <br />6,2, PGIl <br />Cu <br />UN3291, Regulated Medical Waste, n,o.s.. <br />6.2, P011 <br />Cu <br />at <br />UN32el Regulated Medical Waste, n.o.s., <br />6.2, PGI1 <br />Cu <br />ON3201 Regulated Medical Waste, n.o.s., <br />6.2 Pali <br />T B41, 1 21", 1 cu vr. <br />1 <br />Cu <br />LU <br />UN3291 Regulated Medical Waste, s.o.s.. <br />5. ,;1 Tub 42., tc; <br />z <br />6.2, PG11 <br />Cu <br />UN3291Regulated Medical waste, <br />6.2, PGII <br />Cu <br />UN3291 Regulated [VledlcalWaste, n.u.s., <br />6.2, PGli <br />Cu <br />UN3291 Regulated Medical Waste, n.o.s., <br />6.2. PGII <br />Cul <br />CU I <br />3. Generator's Certification. "I hereby declare that the contents of this consIgnmeni are fully and accunst,IY7— <br />Cu I <br />described above by the propotshipping name, and are classified, packaged, marked and labelled/placarded, and <br />are in all respecle In props r cohdition l'or transport I I according Id'applicable International and national gcivernrri7r� regulations!' <br />Ds.iie <br />x PrInicieryped Name_Sifinatuie, <br />X <br />A. TRANSPORTER 1 ADDRESS: Phone <br />-3 t y.e.n Th i.n q.. V..., to, I <br />Z is <br />Applicable Permit Numbers: <br />Dl ­ <br />I <br />z <br />IL <br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br />Print/Type Name Signature Date . ...... <br />5. INTERMEDIATE HANDLER 2 /TRANSPORTER 2 ADDRESS! Phone 41, <br />Applicable Permit Numbers! <br />CWS <br />INTERMEDIATE HANDLER !TRANSPORTER CERTIFICATION: Reculpk of medical waste as described above. <br />Print/Type Name Signature Date <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phone 0; <br />Applicable Permit Numbers; <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Rocolpl of medical waste as described aL)ovp. <br />PtInl/Type Name Signature Date <br />7. DISCREPANCY INDICATION <br />Tmimshrmed cwitaiowrs.. to ft 114 . Nudl Sag Lake, UT <br />A <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 />"'Iceived the above Indicated wastes in accordance with the requirement outlined in that authorization, <br />Piint/Type Narne Signature Dale <br />I FAVF AT 1f-.F:Mfl:D.KTnQ <br />8T/80 39Vd NVO N3AVHW-13 NOSGNIM ZZSOLLP60Z <br />TS:LT ZTOZ/9T/80 <br />