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0 60 Stericycle <br />ExpertSUSTAINABILITY <br />StrongPak <br />Company Name: <br />Store #: <br />Technician: <br />Manifest #- <br />Pharmaceutical Verification Form <br />Date: <br />This form certifies that the pharmaceutical materials listed on the above identified manifest and shipped for <br />destruction under that same manifest, contains none of the following items: <br />• Identifiable DEA controlled substances <br />• Identifiable DEA listed chemicals <br />• Unidentified waste <br />• Pharmaceuticals that carry credit value as a manufacturer return <br />Pharmacist's Printed Name Pharmacists Signature <br />Strongl`ak Retail On -Site Waste Management Systems <br />6264 Crooked Creek Road, Norcross, GA 30092 <br />800.778.7664 www.5tericycle.com 5 <br />