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Medica( Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE,n.o.s., 6.2, PG it <br /> -logic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> 40 Arden Road Hayward Ca 94545 2000359 <br /> Office:510-265-1900 Fax: 510-265-1903 <br /> 2.Generator's Name,Address 3. Transporter 1 Compan Name U.S. EPA ID Number <br /> Telephone Number&Fax Number <br /> 4.Transporter 2 Company Name U.S. EPA ID Number <br /> S. Waste Description 6.Volume 7.Size(Gal) B.Weight;Lbs} <br /> 5b. Red Bag "Biohazard" 6b. Ib 8b '7 <br /> ,r sS <br /> Sid. Trace Chemotherapy 6d. 7d. gd. <br /> C6 Other 6f. 7f. Sf. <br /> lislillilill <br /> NMII <br /> 5h. Qther 6h. 711% Sh. <br /> 9. Gen erator/Offerer's Certification. I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> name,and are classified packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> statefederal regula ons. <br /> 5 � I <br /> i b l <br /> Signat a Print Flame Date <br /> 10. Transporter 1:Acknowledgern en of Receipt of Materials <br /> Signature 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 /> Ficility Name 1 r'✓J �- �' Number/US EPA ID Number J. <br /> ~' l �_t/ WO' <br /> i <br /> Signature Print Name ame Date <br />