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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II <br /> "' 'logic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> '1-3933 Cabot Blvd., Hayward Ca 94545 2002283 <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 <br /> RiAS - �)ekkva c, tA40 <br /> 4.Transporter 2 Company Name U.S. EPA ID Number <br /> 5. Waste Description 6.volume 7.sue(Gal) it.weight(Lbs) <br /> "5b. d Bag uBlohazard" 6b. 7b. qif ab. - <br /> "-9dTraMceChemotherapy 6d. 7d ga <br /> cc Other 6f 7f. e¢ <br /> 5h. Other 6h. 7h. ah. <br /> rna <br /> Genemtar/f3fferer's Certification: i here by declare that the contents of this consignment are fully and accurately described above by the proper shipping <br /> me,and are classified,packaged,marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable local, <br /> te a fader l r latio fl 7 <br /> Signature Print Name Date <br /> 10. 'Transporter 1:Acknowledgeme of Receipt of Materiais t <br /> je5g;�� I -Z <br /> SI ,,Are 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 /> Facility Name ��� �` " Number/US EPA ID Number_. " <br /> /cam . <br /> Sig re Print Name Date 7 <br />