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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE,n.o.s., 6.2, PG It <br /> W-togic Environmental Services&Waste Solutions 1. edical Waste Tracking Form Number <br /> o Arden Road Hayward Ca 94545 2000370 <br /> Office:510-265-1900 Fax:5 10-265-1903 <br /> 2. Generator's Name,Address 3.—Transporter"I Company Name U.S. EPA ID Number <br /> Telephone Number&Fax Number / <br /> Z44-1001/, 4.Transporter 2 Company Name U.S. EPA ID Number <br /> 5. Waste Description 6_volume 7.Size(Gal) S.Weight(Lbs) <br /> 5b. Red Bag"Biohazard" 6b. <br /> 5d. Trace Chemotherapy 6d. 7d. 8d. <br /> cf. Other <br /> fit 7f. 8L <br /> NONE= <br /> Sh. Other 6h. 7h. Bh. <br /> 9. Generator/Offerer's Certification: I hereby declare that the contents of this consignment are fully and accurately described ak�ve 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 /> state and fader re cations. <br /> Signature Print Nam Dat <br /> 10. Transporter 1��:'Acknowledgement of Receipt of Materials / j j 3 <br /> Signature Print Name Date <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> 1 I <br /> Signature Print Name pate <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._ + . umber/U5 EPA ID Number. <br /> Signature Print Name Date <br />