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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG N <br /> ' 'Logic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> r33 Cabot Blvd., Hayward Ca 94545 2002255 <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 /> Telene Number&Fax tuber �- <br /> �, _ }Pe C4 <br /> j 4.Transporter 2 Company Name U.S. EPA ID Number <br /> �. Waste Description 6.volume 7.Size(Gal), 8.weight(Lbs), <br /> 5b. Red Bag"Biohazard'! 6b. 7b. L111 gb. <br /> 5d. Trace Chemotherapy 6d. 7d. sd. <br /> R110ther sf. 7f. 13t <br /> r5h. rather 6h. 7h. 8h, <br /> 9. GeneratorlOfferer's Certificotion. 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 /> state and federal regulations. <br /> C;Z <br /> J!Signatke 2 Pri Name Dam <br /> 10. Transporter 1:Acknowledgement of Receipt of Materials r//Z <br /> Sign ur Print NaWe Date <br /> 11. T spotter 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 /> 1-m 12. <br /> 10 <br /> �,.. <br /> Facility Name... tp { �--" w '� Number/US EPA ID Number r <br /> I r.5--c7/ &E I /�f//`C <br /> Signatu Print Name Date <br />