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MEDICAL WASTE TRACKING FORM NUMBER
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<br /> IN CASE OF EMERGENCY CONTACT: CHEMTREC 1 -800-424.9300 STANDARD MANIFEST 001-03.21 -NOCA
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<br /> I . Generator's Name, Address and Telephone Number
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<br /> 2A, DESCRIPTION OF WASTE 20. CONTAINERTYPE 2C. NO, OF 2D. VOLUME
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<br /> Immmahadmammal East
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<br /> 3, Generator's Certification: "I hereby declare that the contents of this consignment are fully and accurately TOTALS 111hom f Cu Flt
<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 a Ie International and national govern e�nnttaal regulations.""
<br /> PrIntedlYped Name g �-y— — � Date
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<br /> 11i,f :4. TRANsPgRTER1 ADDRESS:
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<br /> a a TRANSPORTElaws R ERTIFICATION : Recelpt of medical waste as describe ve.
<br /> PrinVType Name (R Signature f Date Q� �
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<br /> 5, INTERMEDIATE HANDLER 2 / TRANSPORTER 2 ADDRESS: Phone #:
<br /> Applicable Permit Numbers:
<br /> INTERMEDIATE HANDLER ! TRANSPORTER CERTIFICATION : Receipt of medical waste as described above,
<br /> PrinMpe Name Signature Date
<br /> 8. INTERMEDIATE HANDLER 3 / TRANSPORTER 3 ADDRESS: Phone #:
<br /> ' w ° Applicable Permit Numbers:
<br /> $ IE z INTERMEDIATE HANDLER / TRANSPOI•tTER CERTIFICATION : Receipt of medical waste as described above,
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<br /> — Print/Type Name Signature Date
<br /> 7. DISCREPANCY INDICATION
<br /> yLy 8A. Designated Fact 11111111111 : Loordance
<br /> rnate Facility: 8C, Alternate Facllity: 80. Alternate Facility:
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<br /> TREATM T FAC TY:. 1 thaen authorized by the appifcabfe state agency to accept untreated medicat wastes and that ( have
<br /> t— receive e8k�f�stes nce with the requirement outlined In that authorization ,
<br /> Signature P Date
<br /> ORIGINAL
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