MEDICAL WASTE TRACKING FORM -''a . ,'o.;-. K-.' '.< : . toe'--' •ill > z. IU o 1 . Generator's Name and Mailing Address 3. Telephone Number ( ) 5. Transporter's Name and Mailing Address EPA Med. Waste ID No. I I I I 8. Destination Facility Name and Address 2. Tracking Form Number 4. State Permit or ID No. 6. Telephone Number ( ) 7. State Transporter Permit or ID No. 9. Telephone Number ( ) 10. State Permit or ID No. 1 1 . US EPA Waste Description 1 2. Total No. 1 3. Total Weight Containers or Volume a. Regulated Medical Waste (Untreated) b. Regulated Medical Waste (Treated) c. State Regulated Medical Waste 14. Special Handling Instructions and Additional Information 15. Generator's Certification: Under penalty of criminal and civil prosecution (or the making or submission of false statements, representations, or omissions, 1 declare, on behalf of the generator - ...... that the contents of this consignment are fully and accurately described above and are classified, packaged, marked, and labeled in accordance with all applicable State and Federal laws and regulations, and that 1 have been authorized, in writing, to make such declarations by the person in charge of the generator's operation. Printed/Typed Name Signature Date w '".&'• o I-, o '•?>' •,£C t- 03 '. 2 ': •££-. Ul K "• ' PC . o 0- w ' Z>'-' < - EC :.|_ ,. "z :. O •K". < z • ,i- w Ul o INSTRUCTIONS FOR COMPLETING MEDICAL WASTE TRACKING FORM Copy 1 — GENERATOR COPY: Mailed by Destination Facility to Generator Copy 2 — DESTINATION FACILITY COPY: Retained by Destination Facility Copy 3 — TRANSPORTER COPY: Retained by Transporter Copy 4 — GENERATOR COPY: Retained by Generator As required under 40 CFR Part 259: 1 . This multicopy (4-page) shipping document must accompany each shipment of regulated medical waste generated in a Covered State. 2. Items numbered 1-14 must be completed before the generator can sign the certification. Items 4, 7, 1 0, 1 1 c, & 1 9 are optional unless required by the State. Item 22 must be completed by the destination facility. For assistance in completing this form, contact your nearest State office or Regional EPA office, or call (800) 424-9346. 1 6. Transporter 1 (Certification of Receipt of Medical Waste as described in items 1 1 , 1 2, & 1 3) Printed/Typed Name Signature 17. Transporter 2 or Intermediate Handler (name and address) EPA Med. Waste ID No. I I I I I I I I ! I I I ! Date 18. Telephone Number ( ) 1 9. State Transporter Permit or ID No. 20. Transporter 2 or Intermediate Handler (Certification of Receipt of Medical Waste as described in items 1 1 , 12, & 13) Printed/Typed Name Signature Date 21 . New Tracking Form Number (for consolidated or remanifested waste) 22. Destination Facility (Certification of Receipt of Medical Waste as described in items 1 1 , 12, & 13) O Received in accordance with items 1 1 , 12, & 13 Printed/Typed Name Signature Date (If other than destination facility, indicate address, phone, and permit or ID no. in box 14.) 23. Discrepancy Box (Any discrepancies should be noted by item number and initials) ------- ------- |