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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL.WASTE,ri.os., 6.2, PG II <br /> IP'-Logic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> 0 Arden Road Hayward Ca 94545 2000862 <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 f, lr �L,,g <br /> l�'3� S.. ,� G�,r� Gtr �:�► <br /> 4.Transporter 2 Company Name U.S. EPA ID Number <br /> 5. Waste Description 6.volume 7.Size(Gal) 8.Weight(Lbs) <br /> Mill 1 1: <br /> 5b. Red Bag"Biohazard" 61J. e�t 7b. <br /> Si Trace Chemotherapy 6d, <br /> IN <br /> 4f Other 6f. 7f. 8t. <br /> MEN= I I - <br /> 5 h. Other 6h. 7h. 8h. <br /> SEAMIER I111 1plia, <br /> E EMEM <br /> 9. Generator/Offerees Certification: I hereby declare thatthe contents of this consignment are fully and accurately described above by the proper shippin <br /> name,aftd are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> stateaneral re uiatio <br /> r i <br /> ,fe <br /> 5i re Print Name Date <br /> 10.Transporter 1:Ackn wiedgement of Receipt of Materials <br /> _ SAA <br /> Signature ^Print Name Date <br /> 11.Transporter 2:Acknowledgement of Receipt of Materials <br /> I I <br /> Signature Print Name Date <br /> -Q:. <br /> 12. Discrepancy Indication Section Manifest/MedicidlWaste 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 /> Faicility Name Number/US EPA ID Number .-� lCo. <br /> Signature Print Name Date <br />