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t• <br />• • • Stericycle' <br />®• Vt«uGliilp PuopluRuEucgvry Rlsk: <br />IN CASE OF EMERGENCY CONTACT: <br />1. Generator's Name, Address and TellepWhe Number <br />6.2, PG I <br />1.110291, Regulated Modleal Waste, n.o.s., <br />6.2, PQ I] <br />UN3291 Regulated Medical Waste, n,e,s„ <br />6.2, PGII <br />}-: � 1":ri :.r.'":: ✓•,n SY':i',t`y^•t't iFii �?s,.F',�4 <br />S. Generator's Certification: "I hereby declare that the contents of this consignment are fully, <br />described above by the proper shipping name, and are classified, packaged, marked and label <br />are in all respects in proper condition for iransporl according to applieabic, Irdernatlonal and na <br />PriniedlTyped Name <br />4. TRANSPORTIER 1 ADDRESS; <br />r;. ;;t�,I :.4.:;1,,1.F,+. Ott.<`..I;'1,r:3, <br />fJ) <br />a TRANSPORTER IPFRTIFICATION: R_eipt of �mVical waste as described above, <br />~ PrinUrype Name r 'dJ I I Signature <br />AEC 1.600-424.9800 STANDARD MANIFEST 001.10.06 -STD <br />N '°NNAV 'L Z[H 'Ll '2ny;a;wi j P;Ai;3;� <br />F19G16TRATION # <br />t.1 �.. <br />T7 <br />S'a.r <br />:curately I TOTALS ► <br />acaided, and <br />governmental regulations" <br />2C. NO. OF 21). VOLUME <br />CONTAINERS <br />0 <br />ura , 1.. ,':. Date <br />Phone #: ,5 s.-, :.; ; .:• . . <br />Applicable Permi�Numbers' <br />Date 7 <br />, <br />'u <br />r, • ,, t: <br />CUSTOMER NUMBER �'�."�&� �U �.1'v.;..,' =i <br />Phone 0: <br />6eNerw7'o' <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 /> <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 />> agency to accept untreated medical wastes and that I have <br />rthat authorization. <br />Date <br />I <br />it <br />PAVE AT _lr=NII90At'tf10 l <br />87/07 39dd �JVO N3/1dHWI3 �IOSQNIM ZZ90LLb60Z T9:LT ZTOZ/9T/80 <br />