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a MEDICAL WASTE TRACKING FORM INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM 1.Generator's Name and Mailing Address 2.Tracking Form Number COPY 1 -GENERATOR COPY: Mailed by Destination Facility to Generator COPY 2-DESTINATION FACILITY COPY: Retained by Destination Facility Z COPY 3-TRANSPORTER COPY: Retained by Transporter O COPY 4-GENERATOR COPY: Retained by Generator 4.State Permit or ID No. V As required under 40 CFR Part 259: 1.This multicopy(4-page)shipping document must accompany each shipment of 3.Telephone-Number-(------)--- regulated medical waste generated in a Covered State. F' 2.Items numbered 1-14 must be completed before the generator can sign the certification. 5.Transporter's Name and Mailing Address 6.Telephone Number N P 9 Z Items 4,7,10,11c,and 19 are optional unless required by the State.Items must be --------------------- -------- �) — completed by the destination facility. ------------------------------- For assistance in completing this form,contact your nearest State office or Regional 7.State Transporter Permit or ID EPA office,or call(800)424-9346. EPA Med.Waste ID No. No. 16.Transporter 1(Certcation of Receipt of Medical Waste as described in items 11,12,&13) p 8.Destination Facility Name and Address 9.Telephone Number S ------------------------------- (—) Printed/Typed Name Signature Date � ... 17.Transporter 2 or Intermediate Handler 18.Telephone Number ------------------------------- (name and address) G o 10.State Permit or ID No. W (�) y o 19.State Transporter yc ------------------------------- O EPA Med.Waste ID No. Permit or ID No. O 11.US EPA Waste Description 12.Total No. 13.Total Weight _ Containers or Volume Z aa.Regulated Medical Waste(Untreated) 20.Transporter 2 or Intermediate Handler(certification of Receipt of Medical Waste as described in .14. 1 W ------------------------------- H items 11,12,&13) n. W b.Regulated Medical Waste(Treated) n E; c.State Regulated Medical Waste Cr ------------------------------- Printedrryped Name Signature Date 14.Special Handling Instructions and Additional Information 21.New Tracking Form Number(or consolidated orremanifested waste) 22.Destination Facility(Certification of Receipt of Medical Waste as described in items 11,12,&13) ------------------------------- ❑ Received in accordance with items 11,12,&13 ------------------------------ ZPrintedlTyped Name Signature Date 15-�eDerator'sluettificafion:----- O Under penalty of criminal and civil prosecution for the making or submission of false F (if other than destination facility,indicate address,phone,and permit or ID no.in box 14.) Statemeftts,-repfesef Mion,-er omissions,I declare,on behalf of the generator Z 23.Discrepancy BOX(Any discrepancies should be noted by item number and initials) that the contents of this consignment are fully and accurately P described and are classified,packaged,marked,and labeled in accordance with all applicable W State and Federal regulations,and that I have been authorized,in writing,to make such VedaratIoria-bytWpergm In bha7ge of the generator's operation. P ------------------------------- -------------------------------- --------------------------------