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t <br /> Medical Waste Tracking Form <br /> ON3291 REGULATED MEDICAL WASTE, n.o.s., 6.2,PG II <br /> r BioLogic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> i 3340 Arden Road Hayward Ca 94545 _ low <br /> Ofrice: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 �5 <br /> _ 4.Transporter 2 Company Name U.S. EPA 1D Number <br /> ZAT <br /> ` 5. Waste Description 6.volume 7.size(Gal) 8.Weight(Lbs) <br /> Sb. Red Bag hazard" 6b. 7b. ab. <br /> x. <br /> 5d. Trace Chemotherapy 6d. 7a. Bd. <br /> "' Sf. Other 6f. 7f. 8f. ' <br /> zi <br /> 5h. Other 6h. 7h, sh. : <br /> 9. Generator/Offerer's Certifi ation: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping'; <br /> name,and.are classified,pa ag ,ma ked and lab led/placarded,and are in all respects�in proper condition fortransport according to applicable local, <br /> state and federal regulati <br /> Signate Print Name Date <br /> 10. Transporter l:`AcknoPledgeqhent of Receipt of M13terials Y <br /> A <br /> S, Print NameDAe <br /> ^ <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> 4 4� r <br /> Signature Print Name Date <br /> 12. Discrepancy Indication Section Manifest/Medical Waste Tracking Reference Number 3 ;F <br /> t � <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 lme �= ' <br /> item 12. <br /> x � : <br /> Facility Name ire_ Number/US EPA ID Number ', <br /> F Signature Print Name Date � :: " <br />