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4 <br /> Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.S., 6,2, PG II <br /> ogic Environmental Services&Waste Solutions 1.Medical Waste Tracking Form Number <br /> 3340 Arden Road Hayward Ca 94545 2®o®7 op 9 <br /> Office; 510-265-1900 Fax:51D-265-1903 G <br /> 2. Generator's Name,Address 3.Transporter 1 Company Name U.S. EPA ID Number <br /> Telephone Number&Fax Number <br /> -75 <br /> � � <br /> i C0 q ) ' Q 4.Transporter 2 Company Name U.S.EPA ID Number <br /> ' <br /> 5. Waste Description 6.Volume 7.Size(Gal) 8.Weight(Lbs) <br /> i <br /> . � S <br /> 51b. Red Bag"Biohazard" 6b. 7b. Lit Bb. • <br /> 5d. Trace Chemotherapy 6d. 7d. ad. <br /> } <br /> Y <br /> Other 6f. 7f. 8f. <br /> • � m; nA .. .y int ,i. -.4 <br /> 5h. Other 6h. 7h. 8h. <br /> .: .: . s <br /> 9. Generator/nfferer's Certificotion: I here by declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> name,and are classified,packs ked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> sta federal r ulation .stlx , r <br /> I �1.J 1 j <br /> f�— <br /> Signature f Print Name Date <br /> 10. Transporters' kowledgem ReceiptofMaterials <br /> - I 'A" 1 1�41 <br /> Signat Print Name Dat <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> I <br /> Signature Print Name Date <br /> 12, Discrepancy Indication Section Manifest/Medical Waste Tracking Reference Number <br /> Waste Description Volume Size Weight <br /> 13. Designated Transfer Facility/Treatment Facility:I have been authorized to accept the above waste coveted by this tracking form except as noted In line <br /> i* -4 12. <br /> t l � '"/��j� .� ., 0 <br /> Facility Name Number/US EPA ID Number <br /> '2 I b IV/to 11 <br /> Signature Print Name Date <br /> t, -d Xd3 13I7N3SlJ1 dH WU02 t Z T T T 02 82 unC <br />