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SHA4SSURE 9236 19 <br /> 855-9-SHARPS <br /> I DATE: `t;--Ili <br /> TW <br /> GENERATOR INFORMATION <br /> Aje. <br /> i <br /> DESCRIPTION OF CONTENTS. Regulated Medical Waste <br /> ( pl�% �i t"ttx : 0�� <br /> : <br /> I GENERATOR CERTIFICATE <br /> 9 ae*that this container ho been approved for the mailing of rapuiafed me"waste,has been prepared for makV in aototdarrce wt the <br /> directions for Brat purpose and does not contain excess liquid or nar•maaabla material in violation of applicable PosW Seeds tepu4lona. I AM a <br /> V AWARE THAT FULL RESPONSIBILITY RESTS WITH THE GENERATOR(!MILER)FORANY VIOLATION OF 18 USC 1718 VYHICH MAY RESULT <br /> FROM PLACING IMPROPERLY PACKAGED ITEMS IN THE MAX. I also certify that the contents of ft cwd4trmil aro Atfy and acarWly <br /> described above by proper shipping name and are classed.packed,marked and labeled,and in proper coed bio for cwkw by air aor c n b the <br /> national governmental reguiati".' <br /> 3 , <br /> _ e <br /> Printed Name Sionfture Date <br /> TRANSPORTER INFORMATION ;` <br /> s United States Pal 96rrice <br /> COMMENTS <br /> s s <br /> i <br /> TO-BE COMPLETED BY DISPOSAL SITE ONLY = F <br /> DESTINATION FACILITY - <br /> i MedAssure of Indiana Treatment Facility <br /> 6 II <br /> 1013 South Girls School Road <br /> Indianapolis,IN 46231 <br /> FP 49-61 <br /> 9 c9*ttnaI the car1Mn11 of tlds container have been received,treated,and disposed d in s=rdmm wtlb d WK aids,and federal r WWftne' <br /> Printed Name Signature Date <br /> IN CASE OF EMERGENCY,OR THE DISCOVERY OF g <br /> DAMAGE OR LEAKAGE,CALL 1-877-963-3277 x 500 <br /> i WHITE-GENERATOR-YELLOW-TRANSPORTER-PINK-DESTINATION FACIUTY-GOLD-DESTINATION FACILITY TO MAIL TO GENERATOR <br /> 4 <br />