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STANDARD MANIFEST 001 -70 -06 -STD <br />f CONT4f,` CrIBATREC 1-801JI-42-4-09300 <br />O1S11MMER t,10. 21132 DFRO ON_':,.. <br />0 QUIN PU rp. Svc - <br />'10 9RAW 0VE, HAWN <br />STOGkTON. Ck 06205- 0,2029 <br />M-0 V`V'2*20 7 <br />GENERATOR'S REGISTRATION <br />2A. DtSdAlPTION:bFWA1§ <br />CONTAINERTYPE <br />2C. NO. OF <br />2D, VOLUME <br />k3291 Regulated Medical Waste, r.o.s­. <br />6. PGI1 <br />28 G-21 Tub (sla) CA -7 w P) <br />CONTAINERS <br />Cu Ft. <br />UN3291, Regulated Medical Waste, n.o.sj <br />6.2,PGII: <br />wr Gal.-Lopsw (4. CA., P O <br />= <br />Cu Ft. <br />W_ <br />UN3291, Regulated Medical Waste, n.o.s�., <br />6.21 PGII.:: <br />TRU W <br />Cu Ft. <br />UN3291; Regulated Medical Waste, . n.0 S., <br />T4 1k 11705-Jf, 'Y154 Q0G, 1-10. CLIFT; <br />6.2 Gli <br />Cu Ft. <br />W <br />LIN329111; Regulated Medical Waste, ii.ox., <br />Z. <br />6:2;IPGII i <br />Cu Ft. <br />LIJ <br />UN329t Regulated Modica <br />Vilip <br />Cu Ft. <br />Regulated 'Medical. Waste, n.o.s;, <br />8.2 PGEIKfl_ <br />- Bio" d� rd Bag (4.3 e;,- <br />em% Qnr beaj Ri <br />Cu Ft. <br />ILIN3291; Regulated Medical; Waste; n:o:s., <br />E.2; PGIt <br />Cu Ft, <br />UN32911Regulated M6dicalWaste, 11.0s., <br />Cu Ft. <br />Geneiriatior'sCerb fir .61116n: "I hereby declare that the contents of this consignment are fully and accurately TOTALS III-- <br />' <br />Cu Ft. <br />described above by the proper shipping name, and are classified, packagecl, marked and label led/placarded, and <br />are-1ii alt respects in proper condition for transport according to applicable international and national governmental regulations," <br />X' t4z; <br />F�rintedlTy ed Name m -da" Signature Date <br />it <br />4. TRANSPORTER I ADDRESS-. V Phone <br />-nos is a Through ahipment Applicable Permit Numbers-, <br />AIAW -.v Rego 300 <br />HaaW <br />3 <br />TRANSPORTERt (FICA ipt of medical waste as descrjbed above. fi <br />Print/Typo Name Signature.- Dale <br />5. INTERMEDIATE HANDLER 2 /,TRANSPORTER 2 ADDRESS: Phone <br />ol <br />Applicable Permit Numbers: <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION" . Receipt of medical waste as described above. <br />Name, <br />frjn" Signature Date <br />B. INTERMEDIATE HANDLER 3 /,TRANSPORTER 3 ADDRESS: Phone <br />Applicable Permit Numbers; <br />Nm . < <br />jr. <br />INTERMEDIATE HANDLER /TRANSPORTER CERTIFICATION.- Receipt of medical waste as described above. <br />z <br />z. <br />PirlifiVT a Name Signature Date <br />7. DISCREPANCY INDICATION <br />84. Designated FaCIljty:rq E] 8B. Alternate Facility: 8C. Alternate Facility: 8D. Alternate Facility: <br />e) stiInc. tJnC,111"trjrl SteflGnje.jnrl iJ4q&x1;3Vn <br />U0901N r 9 1 <br />Avi <br />ad .' <br />'ire RizxE <br />'Q Dn 4SW WoM <br />�`A,56 23 <br />"w* I*** Lwx�b 4X? "t, 4 L 'JR6,0T, <br />(ft'1)SZa_i17i.11! 15 ---:74— -Dsr <br />eu 3 <br />� 2_2 <br />LUL <br />U <br />m r6 Peen It 9 <br />pW <br />TREATMENT FACI t I have been authorized by the applicable state agency to accept untreated medical wastes and that I have <br />TR FACILITY:l Ce <br />received the above Indicated Wastes in accordance With the requirement outlined in that authorization. <br />Print/Type NaMe Signature Date <br />I Orn-anc UR <br />*1 to id L k <br />ig <br />