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4-100,111! Stericyde' <br />^p.uwctlyr nuvplu. paavaln7 RVsk: <br />IN CASE OF EMERGENCY CONTACT: <br />1. Generator's Name, Address and TelepTtt;ine Number <br />wq„yivn�. rrna� � I nMV RIi\V rvnm rrVw4pq <br />1.AlIQ.a9Q.�i.4nn STAND V MANIFEE'1-001-10-06-STD <br />°NNW 'L ZIH 'Ll ndg,a,wi P;A1;0 <br />V <br />CusTotmfiNVMBEfl ka.J' F �� ".1'"%"I.�$�1 G9NERATORI0FIMISTRAT10 <br />I�I�Iijil <br />2A, DESCRIPTION OF -WASTE 2B. CONTAINERTYPE' ` , •, 2C, NO. OF 20. VOLUME <br />UI43291. Regulated Medical Waste, n o,s., 1 gib'". E;r, CotVtAIN@q8 <br />I <br />>: ° -4: ] 45$m I o`er G'" �''' 't.� ° °' r <br />®. <br />6,2, PGII g / <br />i - a <br />tr'i•^ :4:;:IS� '��-a,6:.".' `•.I.t I t'�eee2x�:J9. �. <br />3. Generator°a Certification: "I hereby declare that the eonteme of this consignment are lully and aeeuraisly TOTAL:$ <br />described above by the proper shipping name, and are classified, packaged, marked and labelle, /placrardsd, and <br />are In all respects in proper condition for transport according to applicable international and nadgnal governmental regulations;' ` <br />PrintecVTypod Name Signature Date <br />4. TRANSPORTER 'I ADDRESS; <br />.,4, •:k,a',:5,. �,1t,,.", . I- is ` Phone <br />T.4 l 8: t!?',• �+ i ;;t!:•- <br />{ c Q` sN i`' St Applicable Permit Numbers; <br />TRANSPORTER CERTIFICATION: ReeeipI of medical waste as described above. <br />�.�- <br />NfInV'i'ypb Name Signature _ r.,. ' '' Date r.. <br />5. INTERMEDIATE HANDLE14 2 /'TRANSPORTER 2 ADDRESS: Phone"a:i <br />a <br />ow I Applicaple"Permit Numbers: <br />±�S <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medical waeta as desetlbed above. v' <br />PrInU Typo Name Signature Datb«` <br />w <br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER 3 ADDRESS: Phon'li': <br />ow Appllc4ble Permit Numbers: <br />s INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION. Receipt of medical write as described above. <br />PrInt(Type Name Signature Date <br />Ir. DISCREPANCY INDICATION <br />'i �•<�rt5.6�x�t:�� _..._�._ st:u.�'ii2�'e$6$"A'+trl.".i:., �__.._.___._.._ 4ilur Ii I I:u ° �ia�a~�'o .� �,�rti'wr;'�'��... ,'�'-rw-^":, ' <br />Cu <br />6.2, PGII <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 />2-';-T <br />EATMENT FACILITY: I certify <br />that I have been authorized by the applicable <br />statq agency to accept untreated <br />medical wastes and that I have <br />eived the above indicated wastes in acegrdance with the requirement outlined in,that authorization. <br />n <br />Pdntrl'ype Name <br />Signature <br />i <br />Date <br />8T/TT 39tid <br />aVO N3AVHW13 aOSQNIM <br />ZZ90LLV60Z <br />T9:LT ZTOZ/91/80 <br />