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Appendix A — Pharmaceutical Verification Form <br />Pharmaceutical The Pharmacist -in -Charge will be required to sign this Pharmaceutical <br />Verification Verification Form at the time of pick-up certifying that the pharmacy <br />Form hazardous waste removed by StrongPak technicians for disposal contains <br />NO controlled substances. <br />© CVS/pharmacy <br />• <br />Pharmaceutical Verification Form <br />Company Narre: <br />Store t Data: <br />TeOmcian: <br />Manifest#' <br />The pharmaceutical materials listed an the manifest identified by number abm, and sfiipped for destruction <br />under that same manifeX contain no readdy iden0211* DEA roplmd items, no utddentimed M listed <br />cheoicals, and have no credit value as mamurfacturer returns. <br />Ph2rmaost"s Primed Namo PhannacisCs Signature <br />RIM a.saa wn aaaodwa ,. ftftgFm _F .N <br />".W Mw.r�aa Gartree[ Ffolam I :nar< <u =sr PH 0. r.0 cram %ad <br />s„�.�„s ion. rmam i� aaamr�.ru� <br />&brnt3a.c:ccz <br />14 <br />CONFIDENTIAL BUSINESS INFORMATION <br />CVS000010413 <br />