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SHARP-514 <br /> SSURE 846373 <br /> 855- -SHARPS <br /> DATE, <br /> GENERATORINFORMATION <br /> 54 L 0. ) <br /> !,/ <br /> 5aC-7 <br /> DESCRIPTION T Regulated Medical Waste <br /> GENERATOR CERTIFICATE <br /> "i car*that the onatairtar tis been VpmW for the;nailing of mgutatad mer ai;vasW,has been WWared for fnOmg in awadance oMtf ft <br /> directims for that purer and does not contain excess 1IqWd or nomma l"rmunal in viataew of aWtcatk Postal Senoim regUatimm I AM <br /> AWARE THAT Full RSSPONS1B1LrrY RESTS WITH THE GENERATOR(MAIL RI FORANY VIOLATION OF 98 USC 1716 WHICH MAY RESULT <br /> FROM PLACING IMPROPERLY PACKAGED ITEMS IN THE MAIL, l also cerlitp that tha oaotents of;tis Wn-ant ars fiAly and amately <br /> de=bed abave by proper a9 rwmand am c ass€fied,packed,marked and WbeW,and in wow ar4tw fes*cardap by alracawding w the <br /> - <br /> Pfinted gas Signature <br /> � rete <br /> TRANSPORTER INFORMATION <br /> United States Postal Service <br /> COMMENTS <br /> TO BE COMPLETED BY DISPOSAL SITE ONLY <br /> DESTINATION <br /> MedAssure of Indiana Treatment Facility <br /> 1013 South Girls School Road <br /> Indianapolis,IN 46231 <br /> FP 49-6.1 <br /> - <br /> "I rtity that the cxu�tanis of this or€cava raved,iraa od di, �itr aon��il�at(tn [,stats,Brei € saaEicxss <br /> i <br /> Ixrinted Baer Sigrra#z€te i�at� <br /> IN CASE OF EMERGENCY,OR THE DISCOVERY F <br /> DAMAGELEAKAGE,CALL 1-877-963-3277 x 500 <br /> WHITF.GFNFR,AT(IR-Y;l i CNN_TRANRPORTFR•PINK-DRTINAT1014 FACB,"-GOLD-D ST[NATION FACILITY TO MAIL TO GENERATOR '. <br />