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X <br /> , <br /> All <br /> Medical Waste Tracking Form ; <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG IIr <br /> }. t3ioLogic Environmental Services&Waste Solutions 1.Medical Waste Tracking form Number <br /> 3340 Arden Road Hayward Ca 94545 <br /> Office:510-265-1900 Fax:510-265-1903k <br /> 2.Generator's Name,Address 3.Transporter 1 Company Name U.S. EPA ID Number <br /> Telephone Number&Fax Number <br /> d{ (YQ <br /> ct's . <br /> Ce " <br /> 4.Transporter 2 Company Name U.S. EPA ID Number <br /> c3--7,-VZ- <br /> S. <br /> -Z-5. Waste Description 6.Volume 7.size Kali <br /> a.weight(lbs} <br /> MIME=................................. <br /> 5b. Red Bag"Biohazard" 6b. 7b. 8b. <br /> MEN= <br /> 5d. Trace Chemotherapy 6d. 7d. 8d. <br /> n r <br /> .'_ <br /> r <br /> .kY <br /> 6f. 7f. 8f. <br /> E <br /> 5h. Other 6h. 7h. 8h. <br /> 9. Generator/Offerer's Certification: I here by declare that the contents of this consignment are fully and accurately described above by the proper shipping` <br /> name,ano-are classified,packag ,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, Y ` <br /> state and f ral regulatrbr�s. <br /> Signatures'j Print Name €4, <br /> Date71 <br /> 10. Transporter 1 knowl gement of Receipt of Materials ." <br /> 611<ul <br /> Signat VolPrint Name Dae <br /> Es <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials re <br /> alp <br /> I <br /> Signature Print Name Date <br /> 12. Discrepancy Indication Section Manifest/Medical Waste Tracking Reference Number <br /> ,q <br /> Waste Description Volume Size Weight <br /> 13. Designated Transfer Facility/Treatment Facility:I have been authorized to accept the above waste covered by this tracking form except as noted in line <br /> item 12. , <br /> tY <br /> Facility Name _ Number/US EPA ID Number <br /> Signature Print Name Date <br />