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IN E OF EMERGENCY CONTACT.CHEM EC 1-300-424-9 STANDARD MANIFEST 001-10-06-STD <br /> :a CUSTC h?ER IrJ.2I <br /> ar's Name,Address and Telephone Number <br /> CUSTOMER NUMBER::.. :GENERATOR's REGISTRATION# <br /> 2A.DESCRIPTION OF WASTE 26. CONTAINER TYPE 2C. NO.OF 2D. VOLUME- <br /> UN3291.Regulated Medical Waste.n.o.s.. CONTAINERS <br /> 6.2,PGH Cu Ft. <br /> UN3291,Regulated Medical Waste.n.o.s.. <br /> 6.2.PGH Cu Ft <br /> UN3291.Regulated Medical Waste;n.o.s.. <br /> 62.PGII Cu Ft. <br /> UN3291.Regulated Medical Waste,n o.S.. <br /> 6.2.PGII Cu Ft. <br /> 8 UN3291,Regulated Medical Waste.n.o.s., <br /> 62,PGII Cu Ft. <br /> UN3291.Regulated Medical Waste,.n.o.s.. <br /> 62.PGH Cu F4. <br /> UN3291,Regulated Medical Waste',n.o.s., <br /> 62.PGII Cu Ft. <br /> UN3291.Regulated Medical Waste,n.o.s., <br /> 6.2,PGH Cu Ft. <br /> Cu Ft. <br /> 3.Generator's Certification:"I hereby declare that the contents of this consignment are fully and accurately TOTALS Cu FL <br /> described above by the proper shipping name,and are classified,packaged,marked and labeiledtplacarded,and <br /> are in all respects in proper condition for transport according to applicable international and national governmental regulations." <br /> PrintedfFyped Name Signature Date, <br /> 4.TRANSPORTER t ADDRESS: Phone ff: <br /> ILI <br /> Applicable Permit Numbers: <br /> 0 <br /> Q. <br /> Cn ' <br /> Z TRANSPORTER CERTIFICATION: Receipt of medical waste as described above. <br /> PrintfType Blame Signature Date <br /> S INTERMEDIATE HANDLER 2/TRANSPORTER 2 ADDRESS: Phone <br /> a <br /> s Applicable Permit Numbers: <br /> 3� <br /> �Q <br /> v <br /> INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION:Receipt of medical waste as described above.' <br /> PrintTType name Signature Date <br /> u 6 INTERMEDIATE HANDLER 3 1 TRANSPORTER 3 ADDRESS: Phone": <br /> Applicable Permit Numbers: <br /> E z INTERMEDIATE HANDLER/TRANSPORTER CERTIFICATION::Receipt of medical waste as described above. <br /> u <br /> Print/Type Name Signature Date <br /> 7.DISCREPANCY INDICATION <br /> s ., <br /> P,ik Designated Facility: 8B.Alternate Facility: E]8G.Alternate Facility: SB.Alternate Facility: <br /> ® <br /> TREATMENT FACILITY: 1 certify that I have been authorized by the applicable state agency to accept untreated medical wastes and that I`have <br /> m° received the above indicated Wastes in accordance with the requirement outlined in that authorization. <br /> s <br /> PrinUType Name Signature Date <br />