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~' I <br /> L f' <br /> ® WASTE MANIFEST & TRACKING DOCUMENT MANIFEST TRACKING <br /> UN 3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II NUMBER: <br /> Solutions® MA 23557 <br /> 1. GENERATOR'S NAME COMPLETE ADDRESS AND TELEPHONE <br /> 2. GENERATOR (Mailer) CERTIFICATION <br /> I certify that the information provided is true and correct that the contents of this <br /> , <br /> consignment are fully and accurately described below by proper shipping name and <br /> I are classified, packed, marked and labeled and in proper condition for transport by air <br /> according to the applicable national governmental regulations. /also certify that the <br /> Jennifer attached container has been approved for sharps waste mailing, •5as been prepared <br /> for mailing in accordance with the directions for mailing of sharps waste and does not <br /> 207 J St contain excess liquid or non-mailable material in violation of the applicable postal <br /> regulation. 1 am aware that full responsibility rests with the generator (mailer) for any <br /> Lathrop, CA 95330-9482 violation of 18 uSC 1716 which may result from placing improperly packaged items in <br /> the mail. <br /> Printed N the <br /> 3. 1 Quart, 5-quart, _3-gallon, 18-gallon, _28-gallon SI TURE DAT ZS7 <br /> container, lated Medical Waste, UN 3291 <br /> DIRECTIONS FOR GENERATOR (MAILER) Comment Section <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 /> Disposal Site To be completed by disposal site. <br /> Printed certification of receipt and incineration- -I certify that the contents of this <br /> i container have been received, treated and disposed of in accordance with all local, <br /> Specific Waste Industries, LLC state, and Federal regulations." <br /> 6213 Gheens Mill Road Disposal Site present ive <br /> Jeffersonville, IN 47130 <br /> PH: 877-425-2770 Print Name <br /> � Signature <br /> IDEM SW Program ID 10-014 <br /> Date <br /> 24-hour Emei a �onse Phu�ue ?dumber. 800-255-3924 <br />