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'Ster icycle, <br />11W <br />IN CASE OF EMERGENCY CONTACT: <br />1. Generator's Name, Address and TelephV& Number <br />CuaomER NUMBER 4 GENERATOR' <br />2A. DESCRIPTION OF WASTE 26. CONTAINER TYPE <br />UN3291, Regulated Medical Waste, nx,s, <br />6.2� PGII <br />9"s .1 'Put,�� <br />UN3291, Regulated Medical Waste, n.o.s,, :�17 <br />6.2. PGII <br />CC UN3291, Regulated Medical Waste, n,o,s,, 1114-� 41 - 4 a <br />6.2, PGII I <br />UN3291 Reaulsted Medical ftstv, - 24.,( R4 <br />6.2. PGII <br />LU UN3291 Regulated Imedical Waste, n.o.s. A�'4) 'Ct �':i,'r:-f <br />Z 6.2, PGIi <br />LU UN3291Regulated Medical Waste, n,o,6,, <br />6,21 PGII <br />UN3291 Risgulatud Mudleal Waste, <br />6.2, PGII <br />UN3291, Regulated Medleal Waste, n.0 -s-, <br />6.2, Poll <br />0- Generator's Certification: "I hereby declare that the contents of this consignmont are fully at <br />described above by the proper shipping name, and are classified, paCkago. cl, marked and labelle <br />are in I resllp/Ieets In proper condition for Arartsport according to appilcable International and nati, <br />Sic <br />CTRANSPORTER 1 ADDRESS; <br />E <br />L <br />Print/Type Name <br />4 CIERTIFICATIO&-115belpi of <br />above, <br />5. INT15RIVIEDI&EI'HAND21162 / TRANSPORTER 2 ADDRESS: <br />h <br />ifri INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medic <br />g <br />PrinVrype Name Signature <br />6. INTERMEDIATE I-IANDL511 3 1 TRANSPORTER 3 ADDRESS: <br />in <br />Uj <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION: Receipt of medic <br />JEC 1-500-424-0300 STANDARD MANIFEST ooi-io-o6-STD <br />:N0 'ONoffi L ZIR 'Ll 'and'i.awil P@Al;);l <br />REGISTRATION It <br />2C. NO, OF 2D, VOLUME <br />CONTAINERS <br />t) Cu F <br />L. .17 Cu F <br />Cu F <br />Cu F <br />f Cu -F <br />dOCilrately Cu TOTALS 0- <br />F <br />'Pladdid— and <br />al govemmfanial rogulailprIs.' <br />atur6 —:Dale <br />Phone It: k 5-6 S 2 e T 0 9 9 <br />AppIli PorMit NUfters: <br />-�4 <br />Date <br />waster as described above. <br />waste as closerlbed above, <br />Phone it: <br />Applicable Permit Numb= <br />Date <br />Pocne 10: J, <br />Applicable Permit Numbers: <br />II <br />Prini/Type Name <br />Signature <br />Data <br />7, DISCREPANCY INDICATION <br />Teaflskalvd <br />Nadh Sak Lakoj� <br />U'r <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />`REATMENT FACILITY: I certify that I have been authorized by the applicable state <br />agency to accept untreated <br />medical wastes and I 't hat I have <br />the indicated wastes in accordance with the requirement outlined ini <br />authorization. <br />. <br />iceived above <br />�that <br />PrInVType Name <br />—Signature <br />Date <br />I .EAVE Kil UkINIEF4TIZiTil <br />8T/8T 39Vd <br />NVD N3AVHH13 NOSaNIM <br />ZZ90LLV60Z <br />TS:LT ZTOZ/9T/80 <br />