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<br />1. generator's Name, Address and Tele
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<br />2A, DESCRIPTION OF WASTE 2B. CONTAINERTYP
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modlcaIl waste as described above.
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<br />Date,
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<br />6. INTEFJtAEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
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<br />Applicable Permit Numbers:
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<br />STANDARD MANIFEST 001.10.06-ST0
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<br />CONTAINERS
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<br />3. Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS ` ' '/ Cu
<br />described above by the pr9per shipping name, and are classified, packaged, marked and labaliep/placarded,, and
<br />are In all respects; in -proper cotiditign for transport according to appileal to Internallonal and natignal gaverrlenpntal regulations"
<br />Printedrryped Name Signature
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<br />4. TRANSPORTER 1 ADDRESS: �._� t Phone 0 (, �. <:r '� r•� . fr ,:1 rt
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<br />Recelpt of medical waste as described above. � TRANSpQl3'T'ER CERTIFICATION _,.,.
<br />Print/Type Name Signature y Date
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<br />8T/60 39Vd dVO N3AVHW-13 dOSQNIM ZZ90LLb60Z TS:LT ZTOZ/9T/80
<br />5. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS:
<br />Phone #:
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<br />Applicable Pormlt Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of modlcaIl waste as described above.
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<br />Date,
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<br />6. INTEFJtAEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
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<br />INTERMEDIATE HANDIER /TRANSPORTER CERTIFICATION: Receipt or medlegl walla as described above.
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<br />7. DISCREPANCY INDICATION
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<br />-TREATMENT FACILITY: I certify that I have been authorized by the applicable stat' agency to accept untreated
<br />medical wastes and that I have
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<br />,ceived the above indicated wastes in accordance with the requirement outlined inithat authorization.
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<br />Printllype NamSignature _.
<br />Date
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<br />8T/60 39Vd dVO N3AVHW-13 dOSQNIM ZZ90LLb60Z TS:LT ZTOZ/9T/80
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