Laserfiche WebLink
Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE,n.o.s., 6.2, PG f! <br /> '.ogic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> cf$33 Cabot Blvd., Hayward Ca 94545 2002183 <br /> Office:51D-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 � � <br /> 9H 3- /I" Cov R e <br /> 13 3 q. s. 4 ,,� �-' 'aA ian-r41-1-3 <br /> l,, Ck+ 4.Transporter 2 Company Name U.S. EPA ID Number <br /> U01 .33q. 3?-Z-,; <br /> 5. Waste Description 6-Volume 7.Size(Gal) s.weight(Lbs) <br /> ;5d. <br /> Red Bag"Biohazard" 6b. 7b. sb <br /> Trace Chemotherapy 6d. 7d. 8d. <br /> Other 6f af. <br /> al <br /> Sh. Other 6h. 7h. 6h, <br /> e r arV, rer's Ce"cadon: I here by declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> ,an are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> 9.6 <br /> n " T <br /> cal reglas. L <br /> t1 � l <br /> F�//, <br /> at re Print Name Date <br /> 10. Transporter 1:Acknowled entof Receipt of Materials <br /> I L <br /> SI a re Print Name® Date <br /> Transporter 2:Acknowiedgernent of Receipt of Materials <br /> I 1 <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 /> i"12. <br /> j� <br /> d <br /> Facili me 4bt..b s Number/U5 EPA ID Number r` <br /> Si re Print Name Date <br />