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N <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 2000766 <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 Number&Fax Number <br /> 1�Zy9 4.Transporter 2 Company Name U.S.EPA ID Number <br /> J J ll <br /> -36'7 "' d-Vao <br /> 0 3 6 T-44i <br /> 4i <br /> 5. Waste Description 6.Volume 7.Size(Gal) 8.weight(Lbs) <br /> 5b. Red Bag"Biohazard" 6b. 7b. 44 8b. <br /> a <br /> 5d. Trace Chemotherapy 6d. 7d. Bd. <br /> 5f. Other 6f. 7f. 8f. <br /> 5h. Other 6h. <br /> 7n, an. <br /> Sm- wl <br /> .. <br /> 9. Generator/pfferer's Certification: I here by declare that the contents of this consignment are fully and accurately described a bove by the proper shipping <br /> name,and arclassified,packaged,mar ed and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> state and fed e q ions. <br /> I i . <br /> Signature Print N me Date <br /> 30, Transporter 1: ckn led ant of ipt of Materials <br /> I <br /> Signatur Print Name Date <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> i 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 by this tracking form except as noted in line <br /> item 12. <br /> Facility Name IS10 ) 4- LNumber/US EPA ID Number1,5 <br /> Signature J4Print Name Date <br /> T •cl XUJ 13rd3SU-1 dH Wd9Tt21 TT02 Be une <br />