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o <br /> cy) <br /> r�- " V O <br /> rO 0 Q a B 'rD t U . . . co <br /> V x m CL ,,� ro <br /> a u E In ° o m <br /> CL cro a <br /> A :t A ba <br /> LA <br /> a z , <br /> ® WASTE MANIFEST&TRACKING DOCUMENT MANIFEST I RACKING <br /> UN 3291,REGULATED MEDICAL WASTE,n,os„62,PG II <br /> NUMBER: • <br /> Solutions' MA 21812LO <br /> • <br /> N 1.GENERATOR'SNAME COMPLETE ADDRESSANDTELEPHONE 2.GENERATOR(Matter)CER71FICATION <br /> N 1 cedily that the informalion provided Is IN and correct,that the contends of This <br /> consignmemare fully and accurately des <br /> below bypmpershppirq rameand <br /> are classified,packed,marked and labeled and In Propercondt(on for hanspertbyah <br /> � A�n1�eA' according to the applicable national govemmenialregulatians.Ialso certify that the <br /> W�^w allaMedcolilinerhasbegn approvedforsharys waste mai'ing,has beenprepared <br /> Q 238HD6LW ISSWAY for mairingInaaordance with Medireca'onsformaihngofsharpswaste and does not <br /> contain excess kquidornon mallable material in v datlon of the applicable postal <br /> O G9S632A. regulation. Iamaware Met fullnespoobililyresis wilh the generator(marled for any <br /> rn violaUonof 18 USC 1716 which may result from placing improperly packaged items in <br /> cN the mail. ' <br /> Printed Name <br /> U) 3. _10uad, uad, 3-gallon, _181allon, _28yallon SIGN RE DATE �r <br /> L6 container,Re ulaled Medkal Waste,UN 3291 <br /> U) <br /> J � DIRECTIONS FOR GENERATOR(MAILER) Comment Section_ — <br /> Fill out abuva infomnailon ampletoiy. <br /> Sign and date number (Mailer Certification) <br /> O Keep bottom copy of this form for your records. <br /> s' Put IBIS Tracking form in the zip lock bag located on the <br /> p side of the box and seal. <br /> rn To be completed by dlsposal site. <br /> Disposal Site <br /> Pdnled cedificalion of receipt and Incineration.`I cedtiy Mal the contents of IBIS <br /> Q container have been receNed,treated and disposed of in accordance wilh all local, <br /> 0 o state,and Federal regulat' nS." <br /> N cJ <br /> rn �_ Disposal Site R r s <br /> Q A <br /> U Print Name <br /> L <br /> O ax <br /> Signalure <br /> N O <br /> L <br /> Q- Dale <br /> ao <br /> m <br /> c ro 24•hour Emer en Rea o se Phone Number 600.266a924 <br /> 0 M 1��12 � /I Z3 b, <br /> E <br /> a) <br /> CL <br /> r <br /> l- L W <br /> I N <br /> N Q <br /> 0) 00 <br /> m � O n <br /> 0 <br /> U = (ca <br /> F- o a. cn <br />