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SHARPS. <br /> Compliance, Inc. 5098782 RECEIVED <br /> WASTE MANIFEST-TRACKING DOCUMENT <br /> Generator(Mailer)Certification NOV 15 2013 <br /> 'I certify that this container has been approved for the mailing of regulated medical <br /> waste,has been prepared for mailing in accordance with the directions for that purpose, <br /> and does not contain excess liquid or nonmailable material in violation of the applicable ENVIRONMENTAL HEALTH <br /> Postal Service regulations.I AM AWARE THAT FULL RESPONSIBILITY RESTS WITH THE ITT VI <br /> GENERATOR (MAILER) FORA VIOLATION OF 18 USC 1716 WHICH MAY RESULT <br /> FROM PLACING IMPROPERLY PACKAGED ITEMS IN THE MAIL. I also certify that the <br /> contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified,packed,marked,and labeled,and in proper condition for carriage <br /> by air according to the national governmental regulations' <br /> % <br /> All�Iems el t completely ely 4y-,,.th,_q Generator(Mailer). <br /> _, <br /> t <br /> -n <br /> I.PtintedName(Nombm)(Add patientiDnumberifopoicaNe) 2. ript�n of ContenwRfgulatedMedical waste <br /> 65E I&)- OL089AJ7 5r. 711aak, ; <br /> 3.StreerAddress(Direccon) 4.fneratorSignature(Rrnia) <br /> S.City,State and Zip(Gude Estoday codigo Postal) 6.owe Shipped(Fecha de Envio) <br /> 18�- - <br /> 7.Phone(Tekfono) <br /> TRACKING FORM(MANIFEST)DIRECTIONS FOR GENERATOR <br /> • Check above,everything must be filled out completely.YOU MUST SIGN#4 ABOVE. <br /> Keep"Generator"(bottom)copy for your records. <br /> Make sure#4 is signed and#6 is completed with the date container was shipped. <br /> • Put this Tracking Form in the provided ziplock bag on the outside of box and seal, <br /> COMMENTS <br /> TO BEC LET BY TREATMENT SITE ONLY <br /> Printed have been received, <br /> treated and disposed of in accordance with all local,state,and Federal regulations," <br /> Treatment Facility:CFecktheboxof&i,-cmiespmdingbdlity <br /> ❑ Sharps Environmental Services,Inc. 0 Daniels Sharpsmart,Inc. <br /> 1544 NE Loop 1340 Grandview Pkwy,Suite 400 <br /> Carthage,TX 75633 Sturtevant,WI 53177 <br /> Permit NO.1741-A Permit NO.4516 <br /> ❑ Daniels Sharpsmart,Inc. Q Daniels Sharpsmart,Inc <br /> 6611 Chandlery St 10705 Rocket Blvd,Suite 111 <br /> Baltimore,MD 21224 Orlando,FL 32824 <br /> Permit NO.2008- PT-0633 Permit NO.48-67-03021 <br /> ❑ Daniels Sharpsmart,Inc. 0 Curtis Bay Energy <br /> 4144 E Therese Ave. 3200 Hawkins Point Rd. <br /> Fresno,CA 93725 Baltimore,MD 21226 <br /> Permit NO.TS-OST-55 Permit NO.2005-WMI-0036 <br /> IN CASE OF EMERGENCY OR DISCOVERY OF DAMAGE OR LEAKAGE,CALL I.M.772.5657 <br /> Part#100070REV C <br /> FILE <br />