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I I l II I[IIII <br /> SHARPS, <br /> I IIIIIII II�I�II I�III <br /> Defining Change Through Innovation 2441411 t 6wi <br /> Sharps Disposal By Mail' i . I fj <br /> WASTE MANIFEST-TRACKING DOCUMENT <br /> Generator (Mailer) Certification <br /> "I certify that this container has been approved for the mailing of regulated medical waste,has been prepared for <br /> mailing in accordance with the directions for that purpose,and does not contain excess liquid or nonmailable material <br /> in violation of the applicable postal regulation.I am aware that full responsibility rests with the generator(mailer)for <br /> any violation of 18 USC 1716 which may result from placing improperly packaged items in the mail.I also certify <br /> that the contents of this consignment are fully and accurately described below by proper shipping name and are <br /> classified,packed,marked,and labeled,and in proper condition for carriage by air according to the applicable national <br /> governmental regulations." <br /> All items.below must tie filled out completely. <br /> 1.Generator's name(if applicable,add patient identifier number.) <br /> o r <br /> a�11 t _ t <br /> Name(printed)(Not�ribre) 2.Description of Contents <br /> Regulated Medical <br /> e ;t1a t f Y` �a('� [rl` S.�$ Waste <br /> Address(street)(Direcci6n) <br /> 3 3.Generator _ <br /> City(Ciudad) State Zip(important) (Estado) (Codigo Postal) gnature(Firma) <br /> L2 n, 1.11213 <br /> (area code) Phone(Telefono) Date(Fecha) <br /> TRACKING FORM(MANIFEST)DIRECTIONS FOR GENERATOR- j <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 /> Sharps Environmental Services,Inc. Print Name <br /> 1544 NE Loop <br /> Carthage,TX 75633 Signature <br /> Date <br /> TDH 1741/TACB R-9620 <br /> IN CASE OF EMERGENCY,' R DISCOVERY OF <br /> DAMAGE OR LEAKAGE, CALL 1-800-772-5657. <br /> E, R��® Form SHPCO04 Rev052008 <br />