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Medical Waste Tracking Form' <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG 11 <br /> F''-~.ogic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> 33,+0 Arden Road Hayward Ca 94545 20007 <br /> p p <br /> Office:510-265-1900 Fax:510-265-1903 G ( O O <br /> 2.Generator's Name,Address 3.Transporter 1 Company Name U.S. EPA ID Number <br /> Tele{'p�hoinje,Number& Fax Number <br /> ''� <br /> 4.Transporter 2 Company Name U.S.EPA ID Number <br /> �- <br /> 7- 0 <br /> �' : zoo <br /> S. Waste Description 6.Volume 7.Size(Gal) 8.Weight(Lbs) <br /> m <br /> y �:F <br /> 5b. Red Bag"Biohazards' 6b. 7b. .01 Bb. a <br /> r <br /> 'ktLyn Ny <br /> ..�RS X 'f.• Str ,f <br /> 5d. Trace Chemotherapy 6d. 7d. 8d. <br /> t . <br /> S£_,..Other ( <br /> �`` 6f. <br /> i� <br /> r a r xM c�e i tri t � <br /> i:;„. gt n x.x asp _ �`„e, <br /> 5h. Other 6n. 7h. eh. <br /> 9. Generotor/Offerer's Certificotion: I here by declare that the contents ofthis consignment are fully and accurately described above bythe proper shipping <br /> name,and are classified, ckaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> eta a federal r ulat n . <br /> l <br /> s <br /> Signature Print Name Date <br /> 10. Transporter ckn Iedgeme Receipt of Materials <br /> A <br /> Signat Print Name D i&e <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> 1 I <br /> Signatu re 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 covered by this tracking form except as noted in line <br /> fem 12. <br /> Facility Name V.-r Number/US EPA ID Number (�� ! Y1 <br /> e I4 le 7 Oq/Z_C)l\ <br /> Signature Print Name Date <br /> E -d Xdd 13['d3SU-1 dH WU8 T :z T T T 02 82 unr <br />