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WASTE MANIFEST & TRACKING DOCUMENT MANIFEST TRACKING' <br /> UN 3291, REGULATED MEDICAL WASTE, mos.,6.2, PG 11 NUMBER': <br /> Solutions® MA 69- 14 <br /> 1.GENERATOR'S NAME COMPLETE ADDRESS AND TELEPHONE 2.GENERATOR(Mailer)CERTIFICATION <br /> I certify that the information provided is true and correct,that the contents of this <br /> dd <br /> a <br /> consignment are fully and accurately described below by proper shipping name and <br /> are classified,packed,marked and labeled and in proper condition for transport by air <br /> l according to the applicable national governmental regulations.l also certify that the <br /> � � (' (k�} attached container has been approved for sharps waste mailing,has been prepared <br /> (�j`1 t1t#1�✓ for mailing in accordance with the di r s for mailing of sharps waste and does not <br /> W�J contain excess liquid or non mailablii r' a.±tat in violation of the applicable postal <br /> regulation. l am aware that full respo> r'!h�rests with the generator(mailer)for an <br /> violation of 18(ISG 1716 whrch may r4 from placing improperly packaged items n <br /> the mail. <br /> c5?)S , -ij (D` ' 2,� 1 r' ted Name ---- <br /> i 3. 1 Qua 5-quart, _3-gallon, _18-gallon, _28-gallon NATURE DATE <br /> container, Regulated Medical Waste, UN 3291 N <br /> .. Yx., ... yM �.sr�,„k.Ri.: '' "---..a:_..,.�x..,;;,mss s .�.�", 1` ,.,rw'n•x: <br /> Fill out above information completely <br /> • Sign and date number 2(Mailer Certification) <br /> • Keep bottom copy of this form for your records. <br /> • Put this Tracking form in the zip lock bag located on the <br /> side of the box and seal { <br /> .:may,,'t"...--:.., <..Y,. � $ ...;: %�>i.,... :f y; Y,k. G� I'�V ���^�.���it',�.'r ��:..�Xaf •¢i �f'37/ <br /> Printed certification of receipt and incineration-1 certify that the contents of this <br /> container have been received, treated and disposed of in accordance with all local, <br /> state:and Federal re utatrons <br /> l Disposal Site Rep•` . <br /> Print Name <br /> { <br /> Signature ~' <br /> Date <br /> t <br /> , 24-hour Einer enc Res once Phone Number: 800 <br /> r <br />