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Medical Waste Tracking°Form <br /> 0 3cf to-3 3 <br /> 5UN3291 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 <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 /> A _ 4.Transporter 2 Company Name U.S. EPA ID Number <br /> Lod* , <,., <br /> Ir �c7 d,+'" <br /> r ., <br /> 5. Waste Description 6.volume 7.size(Gal) 8.weight(Lbs) ` <br /> _ 5b. Red Bag,"Biohazard" 6b. 7b. - sb. y <br /> 5d. Trace Chemotherapy 6d. 7d ad <br /> MENEM= <br /> 5f. Other 6f. 7f, sf. <br /> 5h. Other 6n. 7h. sh. <br /> 9. Generator/Offerer's Certift ation: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping.{ <br /> e name andareclassified a " <br /> p ged,marked and lab led/placarded,and are in all respecttin proper condition for transport according to applicable local, <br /> state and federal regulate <br /> Signatoe,�fgp Print Name Date <br /> 10. Transporter.l:Acknojkledgertient of Receipt of Mbterials <br /> z"i, A""-)A Vmt, <br /> S' ur Print Name D 2 <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> a.P <br /> Signature Print Name Date <br /> 12. Discrepancy Indication Section Manifest/Medical Waste Tracking Reference Number <br /> f 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 lene <br /> -: item 12. ° <br /> Y Facility Name w,l i ' <br /> Number/US EPA ID Number <br /> I <br /> Signature Print Name Date <br />