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UNIVERSITY OF THE <br /> PACIFIC <br /> Thomas J ]-o»g School of <br /> Hiarmac��& I-lealthl;Iealth Sciciiccs' <br /> SHARPS SIGN-OUT SHEET <br /> Date anger July 1, 2013 —July 31, 2014 <br /> Please Note: This is a LEGAL PROCESS.Your name is a guarantee that all appropriate protocols <br /> have been followed: <br /> 1) You agree to check out and return the Sharps Container and transport tote. <br /> 2) The Sharps Container must hold only what is listed on the label. <br /> You can be charged$10 for any additional items in the Sharps Container you checked <br /> out/in.. <br /> Write legibly and clearly. <br /> Include ALL information requested below. <br /> DATE DATE <br /> SHARPS# QTY NAME PHONE# CHECK OUT CHECK IN <br /> = � J <br /> met 110 VA_alp V&,o �51 <br /> ,S7 <br /> 365�a 3 6m Lir, 6A 36330' 3/14 1H 1 rVk <br /> (Irk Le- ' H-ma3 H <br /> has® <br /> VM* 71 —S 1 Iq y <br /> 1.4 Qt = Sharps # 201-300 1 GAL = Sharps # 101 —200 5 Qt= Sharps # 1- 100 3 gal = 300 - 400 <br />