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Medical Waste Tracking Form

GENERATORM edical Waste Tracking FormEmergency Response Number:3. Telephone number:1. Generator s Name and Mailing Address:5. Transporter s Name and Mailing Address:8. Destination Facility Name and Address:2. Tracking form Number:4. State Permit or ID No. Number:7. State Transporter or ID Number:10. State Permit or ID s Certification:11. USDOT Shipping Name:a. x Regulated Medical Waste , ,UN3291, Weightor volume14. Special Handling Instructions:14.(a) Additional InformationINSTRUCTIONSTRANSPORTERDESTIN ATIONI nstructions for completing the Medical Waste Tracking form :Print/Type NameSignatureDatePrint/Type Name SignatureDateCopy 1 - GENERATOR COPY: Mailed by Destination Facility to GeneratorCopy 2 - DESTINATION FACILITY COPY: Retained by Destination FacilityCopy 3 - TRANSPORTER COPY: Retained by TransporterCopy 4 - GENERATOR COPY: Retained by multi-copy (4 page) shipping document must accompany eachshipment of regulated Medical Waste generated in New York numbered 1-14 must be completed before the generator cansign the certification.

GENERATOR Medical Waste Tracking Form Emergency Response Number: 3. Telephone number: 1. Generator’s Name and Mailing Address: …

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