7.0_Attachment_07_-_Example_of_a_Certificate_of_Destruction.doc

SP453017R000X

Guam HW

Disposal Facility Name

Address

Contact Information

CERTIFICATE OF DESTRUCTION

Certificate No.:

Pickup Date:

Task Order #:

Date Received:

Manifest Number:

CLIN#

Treatment Disposal Date

Method

I certify, to the best of my knowledge, the above listed items were treated/disposed of as indicated in accordance with applicable laws and regulations at this permitted treatment, storage and disposal facility and have been rendered unusable and unrecoverable.

Print Name

Signature

Date

Print Title