Laserfiche WebLink
Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II <br /> ^toLogic Environmental Services&Wasbe Solutions 1.Medical Waste Tracking Form Number <br /> 833 Cabot Blvd., Hayward Ca 94545 2002317 <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 .in <br /> 01)03 <br /> u i ca 4.Transporter 2 Company Name U.S. EPA ID Number <br /> Z�°1 ,3��1.3�s2s <br /> 5. Waste Description 6.Volume 7.size(Gall 8.Weight{Lbs} <br /> 5b. Red Bag"Blohazard" eb. 7b. sb. <br /> NAME <br /> NO MM <br /> Sd. Trace Chemotherapy gd. 7d. <br /> lid. <br /> POther 6f 7f, 8i <br /> 001M <br /> =Other 6h. 7h. sn. <br /> =EEE= EM=JE <br /> 9. Gen toflofferer's Certfficatfon: I here by declare that the contents of this consignment are fully and accurately described above by the groper shipping <br /> name, are classified,packaged,marked and labeled placarded,and are in all respects in proper condition for transport according;to pplicable local, <br /> state fed ral gulationAlls <br /> f <br /> Sig at re Print Name Date <br /> 10.Trans orter 1:Acknowle ent of Receipt of Materials <br /> Y <br /> i ure Print Name Date <br /> 1. Transporter Z:Acknowledgement of Recelpt 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 apt the above waste covered by this tracking form except as noted in tine <br /> item 12. <br /> Facility Name__ umber/US EPA ED Number + <br /> ature Print Mame Date <br />