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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II <br /> BioLogic Environmental Services&Waste Solutions 1.Medical Waste Tracking Form Number y" <br /> 3340 Arden Road Hayward Ca 94545 <br /> Office:510-265-1900 Fax:510-265-1903 <br /> 2.Generator's Name,Address 3.Transporter 1 Company.Name U.S. EPA ID Number 777 <br /> Telephone Number&Fax Number <br /> fi ... �12�"#I"�.��� X14✓ a ' aw <br /> i 4.Transporter 2 Company Name U.S. EPA ID Number <br /> a u <br /> —31 414 <br /> t <br /> 5. Waste Description 6.volume 7.size(Gal) 8.Weight(Lbs) Y <br /> MEE= 3 <br /> 5b. Red Bag "Biohazard 6b. 7b. 8b. <br /> 5d. Trace Chemotherapy 6d. 7d. ad. a <br /> Sf. Other 6f. 7f. af. f <br /> ., <br /> MIN 'GEM <br /> 5h. Other 6h. 7h. 8h. <br /> p7lt <br /> 9. Generator/Offerer's Certification:fer' by declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> name,and ref classified,packanar d nd labeled/placarded,and are in all r pects in proper condition for transport accorcpng to ap licabie local <br /> state acid ,�gp' raI cul tions{./� p s <br /> Signature Print Name Date <br /> 10. Transporter 1:A nowledgement of Receipt of Materials + <br /> Ov, Lk <br /> Si r Print Name Dat <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> Signature Print Name Date ' <br /> 12. Discrepancy Indication Section Manifest/Medical Waste Tracking Reference Number f <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 lino-,"i", ' <br /> item 12. <br /> Facility Name ' g Number/US EPA ID Number • ` <br /> Signature Print Name Date ' <br /> -- <br /> - . <br />