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wwra. <br /> WASTE MANAGEMEM <br /> TRACKINGFORM <br /> 1.GENERATOR NAM OR PATIENT IDENTIFIERS <br /> 1Z, MOM <br /> ==ME <br /> USPS Regulated <br /> Medical Waste Mailing ManItW Generator(Mailer)Certification <br /> "I certify that this container has been approved for the mailing of regulated medical waste,has <br /> been prepared for mailing in accordance with the directions for that purpose,and does not <br /> 2.DESCRIPTION OF CONTENTS contain excess liquid or nonmailable material in 0oiation of the applicable Postal Service <br /> regUtptions.I AM AWARE THAT FULL RESPONSIBILITY RESTS WITH THE GENERATOR(MAILER)FOR <br /> ANY VIOLATION OF 18 USC 1716 WHICH MAY RESULT FROM PLACING IMPROPERLY PACKAGED <br /> 3.GEOR SIGNiTEMS IN THE MAIL.I also certify that the contents of this consignment are fully and accurately <br /> NERATFURE <br /> described above by proper shipping name and are classified,packed,marked,and labeled,and in <br /> proper condition for carriage by air according to the national governmental regulations." <br /> 7 <br /> YVI <br /> -V <br /> ORION <br /> Disposal Facft pftW Certificatiork of Receig and DISPOSAL SITE REPRESENTATIVE <br /> wao�te mpmarlfIqt,rj, Trealbuent"I certify that the contents of print Name: <br /> this container have been received, treated <br /> and disposed of in accordance with all local, Signature: <br /> state,and federal regulations." Date, <br /> PeTmit <br /> --------------------------------------- Fold an Dotted Line __-•__-_------------------------------- <br /> TRANSPORTER IIM HANDLER TRANSPORTER/INTERMEDIATE HANDLER TRANSPORTER/INTERMEDIATE HANDLER <br /> E] WAMC,Inc ;�nan 0 WMNS Woodstock <br /> 71�lz z 4280 Bandini Blvd. 315 Bell Park Drive <br /> Anahuar,7Z 77514 Vernon,CA 90023 Woodstock,GA 30188 <br /> 409.267.3913 323.307.0514 770.517,4203 <br /> Permit#.-XSW 50114 Permit#. 7SIOST-81 Permit#:EFD 028-042P <br /> Print Name: Signature: Date: <br /> TRACKING FORM <br /> INSTRUCTIONS FOR GENERATOR <br /> 1. Check above that all is completed. <br /> 2. Keep"GENERATOR" copy for your records. <br /> 3. Sign on"GENERATOR"line. <br /> 4. Fold and put tracking form in bag on side of box and seat. <br /> COMMENTS: <br /> For assWance you may contact us at our website <br /> at wintracker com or dial 1-800-664ol 434 <br /> w1uno <br /> WASTE MAPJAGEMEMT <br /> Document Control No: 11022010 <br />