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SHARPS14 SSURE <br /> A MEDASSURE COMPANY 000965403 <br /> 855-9-SHARPS <br /> DATE: 07/11/2023 <br /> GENERATOR INFORMATION <br /> Lia Vang <br /> 10255 Paulsell Drive <br /> Stockton, CA, US 95209 <br /> DESCRIPTION OF CONTENTS: Regulated Medical Waste WEIGHT: 4 lbs <br /> GENERATOR CERTIFICATE <br /> "I certify that this container has been approved for the mailing of regulated medical waste, has been <br /> prepared fo_mailing in accordance with the directions for that purpose and does not contain excess <br /> liquid or non-mailable material in violation of applicable Postal Service regulations. I AM AWARE <br /> THAT FULL RESPONSIBILITY RESTS WITH THE GENERATOR(MAILER) FOR ANY VIOLATION OF <br /> 18 USC 1716 WHICH MAY RESULT FROM PLACING IMPROPERLY PACKAGED ITEMS IN THE MAIL. <br /> I also certify that the contents of this consignment are fully and accurately described above by proper <br /> shipping na-ne and are classified, packed, marked and labeled, and in proper condition for carriage by <br /> air according to the national govemmental regulations." <br /> TRANSPORTER INFORMATION <br /> United States Postal Service <br /> COMMENTS <br /> TO BE COMPLETED BY DISPOSAL SITE ONLY <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> DESTINATION FACILITY <br /> MedAssure of Indiana Treatment Facility <br /> 1013 South Girls School Road <br /> Indianapolis, IN 46231 <br /> FP 49-61 <br /> I certify that the contents of this container have been received,treated,and disposed of in accordance with all local,state,and <br /> federal regulations. <br /> Wadie Vance `Kee -T 07/11/2023 <br /> Printed_Name Signature Date <br /> IN CASE OF EMERGENCY, OR THE DISCOVERY OF <br /> DAMAGE OR LEAKAGE, CALL 1-877-963-3277 x 500 <br /> WHITE-GENERATOR YELLOW-TRANSPORTER PINK-DESTINATION FACILITY.GOLD-DESTINATION FACILITY TO MAIL TO GENERATOR <br />