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0 <br /> 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 <br /> 3340 Arden Road Hayward Ca 94545 2000765 <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 <br /> Telephone NumberOO&Fax Number <br /> 13-3q 5` Ham, !�-.�e� �7 c a <br /> C,A 4 G2LtL 4.Transporter 2 Company Name U.S.EPA ID Number <br /> Z-09 . 31f 7719 <br /> 5. Waste Description 6.volume 7.Size(Gall 8.Weight(Lbs) <br /> ���g A <br /> ate+.'. <br /> .• cra<..., r a <br /> 5b. Red Bag"Biohazard" 66. 7b sb <br /> 5d. Trace Chemotherapy 6d. 7d. ed. <br /> h`6ta •.i M1. E - <br /> 1' � ';f,.1 f�I.. � 3 �, .I�. j • ,sr:5t. 3. � i <br /> T` <br /> ef. Other <br /> 6f. 7f. af. <br /> if <br /> Stir <br /> ' _ �""' <br /> . . la7d <br /> 5h. Other h. 7h.7h <br /> 7h. 8h. <br /> A a,M x <br /> I 2a <br /> 4. Generator/Offerers Certification: I here by declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> na me,and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to a pplicable local, <br /> state and#eral Mations. <br /> I —� ' r I <br /> Signat Print Name Dat <br /> 10. Transporter • knowl ge Receipt of Materials <br /> f <br /> Arm* <br /> Signa u Print Name <br /> Date <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> 1 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 covered bythis tracking form except as noted in line <br /> item 12. �j <br /> Facility Name �0 1 t.. C, Number/US EPA ID Number X1 _ <br /> L <br /> Signature Print Name Date <br /> 2 -Cl Xd3 13Cd3SU-1 dH WUL T t Z T i T o2 Ba unC <br />