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So -2 4ARPS <br /> Il�li�►;;::;11ll1lllili��i�ilil�llliil�li��i <br /> Defining Change Through Innovation... <br /> Sharps Disposal By Mail" 3141562 <br /> WASTE MANIFEST-TRACKING DOCUMENT <br /> Generator (Mailer) Certification <br /> "I certify that this container has been approved for the mailing of regulated medical waste,has been prepared for <br /> mailing in accordance with the directions for that purpose,and does not contain excess liquid or nonmailable material.A <br /> in violation of the applicable postal regulation.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 items in the mail.I also certify <br /> that the contents of this consignment are fully and accurately described below by proper shipping name and are <br /> classified,packed,marked,and labeled,and in proper condition for carriage by air according to the applicable national <br /> governmental regulations." <br /> All items below must be filled out completely. <br /> 1.Generator's name(if applicable,add patient identifier number.) I <br /> Name(printed)(Nombre) 2.Description of Contents <br /> Regulated Medical <br /> Waste <br /> Address(street)(Direccion) <br /> 3.Ge4erat <br /> City(Ciudad) State Zip(important) (Estado) (Codigo Postal) Stgnature(Firma) <br /> (area code) Phone(Telefono) Date(Feclt ) j <br /> TRACKING FORM (MANIFEST)DIRECTIONS FOR GENERATOR I+ i <br /> • Check above,everything must be filled out completely. l <br /> • Keep"Generator"(bottom)copy for your records. <br /> • Make sure item number 3 is signed and dated. <br /> • Put this Tracking Form in a ziplock bag on side of box and seal. <br /> COMMENTS . <br /> - t <br /> TO BE COMPLETED BY DISPOSAL SITE ONLY <br /> ! Printed certification of receipt and incineration-"I certify that the contents of this container have been <br /> received,treated and disposed of in accordance with all local,state,and Federal regulations." <br /> DISPOSAL FACILITY DISPOSAL SITE REPRESENTATIVE <br /> Sharps Environmental Services,Inc. Print Name <br /> 1544 NE Loop <br /> Carthage,TX 75633 Signature <br /> Date <br /> TDH 1741/TAC13 R-9620 <br /> I <br /> IN CASE OF EMERGENCY, OR DISCOVERY OF r <br /> DAMAGE OR LEAKAGE, CALL 1-800-772-5657 <br /> GENERATOR ForniSHPC0o4 RM52008 <br /> I <br />