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0 ®• Stericycle" IN CASE OF EMERGENCY CONTACT; CHEMTREC 1-800-424-9300 STANDARD MANIFEST Doi --I 0-06-STO
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<br />I. Generator's Name, Address and TelepWne Number .1, R
<br />CUSTOMER NUMBER REGISTRATION
<br />GENERATOM
<br />2A. DESCRIPTION OF WASTE
<br />28. CONTAINER TYPE'
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<br />2C. NO. OF
<br />2D. VOLUME
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<br />3. Generator's Certification: 1 hereby declare Mat the conLenh5 of this consignment are fully and accurately TOTALS PIP-
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<br />described above by the proper shipping name, and are clas;Sifled, packaged, marked and labelled/placarded, and
<br />al" a ji cls /In proper condition for transporl according to applicable international and natic nal govern7ntal regulg�ions,".
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<br />Date
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<br />TRANSPORTER CERTIFICATION: Recelpi or modical waStu as described above.
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<br />Phone #:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: I;ecelqt of medle
<br />I waste as described above.
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<br />6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS:
<br />Phone #:
<br />Applicable Permit Numbers:
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<br />INTERMEDIATE HANDLER /TRANSPORTER CER71FICATION: Receipt of medical waste as described above,
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<br />Print/Type Name Signature
<br />Date
<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 medical wastes and that i have.-
<br />received the above indicated wastes in accordance with the requirement outlined InIthat authorization.
<br />PrinVType Name —,Signature
<br />Date
<br />II =A%IV AT
<br />8T/9T 39VJ NVO N3AVHW-13 NOSGNIM ZZSOLLV60Z TS:LT ZTOZ/9T/80
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