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b} 'I TRACKING DOC ENT <br /> Ta vp <br /> !i AKrS. 1860362 <br /> WASTE MANIFEST-TRACKING DOCUMENT <br /> Generator (Mailer) Certification <br /> "I certify that this container has been approved for the mailing of sharps waste,has been prepared for mailing in <br /> accordance with the directions for that purpose,and does not contain excess liquid or nonmailable material in violation <br /> of the applicable postal regulation.I am aware that full responsibility rests with the generator(mailer)for any violation <br /> of 18 USC 1716 which may result from placing improperly packaged items in the mail.I also certify that the contents of <br /> this consignment are fully and accurately described below by proper shipping name and are classified,packed,marked, <br /> and labeled,and in proper condition for carriage by air according to the applicable national governmental regulations." <br /> All items below must be filled out completely. <br /> 1. Generator's name(if applicable, add patient identifier number.) <br /> Name (printed) (Nombre) 2. Description of Contents <br /> Regulated Medical <br /> Waste - Sharps <br /> Address (street) (Direcci6n) <br /> 3. Generator <br /> City(Ciudad) State Zip (important) (Estado) (Codigo Postal) Signature(Firma) <br /> (area code) Phone(Telefono) Date(Fecha) <br /> TRACKING FORM (MANIFEST) DIRECTIONS FOR GENERATOR <br /> • Check above,everything must be filled out completely. <br /> • Keep"Generator"(bottom)copy for your records. <br /> • Make sure item number 3 is signed and dated. <br /> • Put this Tracking Form in a ziplock bag on side of box and seal. <br /> COMMENTS <br /> TO BE COMPLETED BY DISPOSAL SITE ONLY <br /> Printed certification of receipt and incineration-"I certify that the contents of this container have been <br /> received,treated and disposed of in accordance with all local, state, and Federal regulations." <br /> DISPOSAL FACILITY DISPOSAL SITE REPRESENTATIVE <br /> City of Carthage Print Name <br /> Panola Co. Resources Recovery Site 01 <br /> 1544 NE Loop, Carthage,TX 75633 Signature <br /> Date <br /> TDH 1741/TACB R-9620 <br />