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<br />IN CASE OF EMERGENCY CONTACTz CHEMTRFn 1.
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<br />1. Generator's Name, Address and Telep7one Number
<br />CUSTOMER NUMBER ". ii�' 1 11,
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<br />STANDARD MANIFE8Tooi-io-o6-9Ti)
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<br />8T/VT 39Vd NVO N3AVHW-13 NOSGNIM ZZ90LLV60Z TS:LT ZTOZ/9T/80
<br />2A. DESCRIPTION OF WASTE
<br />2B, CONTAIN51`ITYPE!'
<br />2C. NO. OF
<br />2D. VOLUME
<br />=291 Regulated Medical Waste, 11.o.s..
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<br />CONTAINERS
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<br />URegulated Medical Waste. ri,o.s.,
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<br />.2N3291
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<br />UN3291 Regulated Medical Waste, r.O.S..j,
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<br />6.2, PG I
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<br />UN3291, Regulated Muilual Waste, ri.o.s.,
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<br />IX
<br />6.2, 17011
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<br />Ulq329i, RogulaNcl Mudlual Waste, n,0,5.,
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<br />UN3291. Regulated Medical Waste, n.o.u.,
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<br />UN3291, ReguWad Medical Waste, r.o.s..
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<br />3. Generator's CertCertification:anoation! "I hereby declare that the contents of this consignment are fully
<br />aocuratoly ATOTAL Cu I—sold E:
<br />described above by the proper shipping name, and are classified, packaged, markod and labelled/placarded,
<br />and
<br />are in all respects in proper condition for transport according to applicable International and national
<br />governmental regulations."
<br />Prinledrryped Name _Slgba1ure.WALq&
<br />—Date
<br />A. TRANSPORTER 1 ADDRESS:
<br />Phone #: S !:, a J_
<br />Sl:ecic*!jJ'cil,:i, 1
<br />4 Applicable Permit Numbers:
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<br />2
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<br />TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br />'v
<br />Print/Type NameSignature
<br />Date
<br />5. INTERMEDIATE HANDLER 2 ITRANSPoxirc.R 2 ADDRESS: phone 6.
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Flocelpi of mc:dlc�l wasNj as cluscribed above.
<br />Pdnt/'Iype Name Signature Date
<br />6. INTERMEDIATE HANDLER 3 /TRANSPORTER $ ADDRESS: Phone #:
<br />Applicable Permit Numbers:
<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medic waste as described above.
<br />PrInt/1`ype Name Signature Dale
<br />7. DISCREPANCY INDICATION'
<br />7T.4.rulu,nrej ft 1-o . NoelSad Lake, UT'
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<br />U nnTREATMENT FACILITY: I certify that I have been authorizy the applicable stat
<br />0"b
<br />to accept untreated medical wastes and that I have
<br />" wived the above indicated wastes in accordance with the, requirement outlined In
<br />t hat authorization,
<br />PrintrType Name Signature
<br />Date
<br />8T/VT 39Vd NVO N3AVHW-13 NOSGNIM ZZ90LLV60Z TS:LT ZTOZ/9T/80
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