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"M IN CASE OF EMERGENCY CONTACT:CHEMTREC 1—t MEDICAL WASTE TRACKING FORM NUMBER
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<br /> in• Stericycle' 1W -800-4 9300 STANDARD MANIFEST 001-10-06-STD
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<br /> I.-,* Protecting People.Reducing Risk: CUSTOMER NO.21132
<br /> 1.Generator's Name;Address and Telephone Number
<br /> ATT.N j a
<br /> S,11i JCI�Ail.'-1.41 Iffrl-K'Tlhl: 11.0111L.Eof
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<br /> J-51. 10:ACIFIG
<br /> STOCKV1,141
<br /> CUSTOMER NUMBER 6I -1.9 GENERATOR'S REGISTRATION#
<br /> 2A.DESCRIPTION OF WASTE 2B. CONTAINER TYPE 2C.NO.OF 2D. VOLUME
<br /> UN3291 Regulated Medical Waste,n.o.s., CONTAINERS
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<br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS ® c.Ft.
<br /> described above by the proper shipping name,and are classified,packaged,marked and labelled/placarded,, -
<br /> are in all respects in proper c9aciffierri for transport according to applicable international and national governmental regulatipg." fi,
<br /> XPrirtedfFyped Name y IN 1 (4 '71 -Signature Date
<br /> 4.TRANSPORTER I ADDRESS: Phone#: V_rzl-
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<br /> W Applicable Permit Numbers:
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<br /> Z TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.
<br /> PrintfType Name Signature Date
<br /> 5.INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS:
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<br /> w<cc Applicable Permit Numbers:
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<br /> W oic INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
<br /> Print/Type Name Signature Date
<br /> 6.INTERMEDIATE HANDLER 3/TRANSPORTER 3 ADDRESS: Phone#:
<br /> Applicable Permit Numbers:
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<br /> CL Z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION: Receipt of medical waste as described above.
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<br /> PrintfType Name Signature Date
<br /> 7.DISCREPANCY INDICATION
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<br /> 8A.Designated Facility: 813.Alternate Facility: 8C.Altemate Facility: E]8D.Alternate Facility:
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<br /> ag TREATMENT FACILITY:I certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I have
<br /> received the above indicated wastes in accordance with the requirement outlined in that authorization.
<br /> PrInUrype Name Signature Date
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