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<br /> j. MEDICAL WASTE TRACKING FORM NUMBER
<br /> Stencycle' IN CASE OF EMERGENCY CONTACT: CHEATTREC 14=4244W STANDARD MANIFEST 001 .03.21 -NOCA
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<br /> I � 01t LQ :r. ; L .a • fj CUSTOMER NO. 21132
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<br /> I . Generator's Name, Address and Telephone Number
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<br /> CwromEn Numun Goteau►TOR's REGISTRATION #
<br /> 2A. DESCRIPTION OF WASTE 28. CONTAINERTYPE 2C. N04 OF 2D. VOLUME
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<br /> 3. GerAmoMor's CerUNcstfon: 41 hereby declare that the oontente of this consignment are fusty and aocuretety TOTALS ► Cu Ft.
<br /> ' described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and
<br /> are In all respects in proper condition for transport according to applicable international and national governmental regulatims.'
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<br /> 4. TRANSPORTER I ADDRESS: Phone #: ,.. ,
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<br /> _ ia . : I ( ; Vf ( tit; . ' I hit ; Ir* 0 11mitfUE1 ':? It1 ; Il11 . : lIi Applicable Permit Numbers,
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<br /> TRANSPORTER CERTIFICATION: Receipt of medical waste as descdbed
<br /> Pdnt/Type Name Signature to '"�_ Date
<br /> lefto 6. INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> a � f Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PdnU ype Name Signature Date
<br /> ro 6. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> Applic" Permit Numbers:
<br /> INTERMEDIATE HANDLER / TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> PdnUfype Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> Aaemate Facility: ttC. Attarnata Fadifty: SD. Akemata Facllily:
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<br /> REATMIfdKIhat I hav been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> Imo— eived t 9 ve indicated wastes rdance with the requirement outlined in that authorization .
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