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Medical Waste Tracking Form <br /> UN3291 REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II <br /> Biologic Environmental Services&Waste Solutions 1. Medical Waste Tracking Form Number <br /> 19833 Cabot Blvd., Hayward Ca 94545 <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 °r <br /> d,Y AC c�Y pd' b.zY •9*'.' 4� .,. �gr� R -r t.f k..W .r" -^ g. { <br /> } 4.Transporter 2 Company Name U.S. EPA ID Number <br /> , , <br /> 5. ; Waste Description 6.Volume 7.Size(Gal) 8.Weight(Lbs) <br /> 5b. Red Bag"Biohazard" 6b. 7b. q41sb. <br /> 5d. Trace Chemotherapy`� 6d. 7d. 8d. <br /> 5f. Other 6f. 7i si <br /> MEN= <br /> 5h.;Other6h. 7h. ` 8h. <br /> 9. Generator/Offerer's Certification: I here by 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 /> Signature Print Name Date <br /> 10. Transporter owled.Rement of Receipt of Materials <br /> Signature,..'` Print Name Date <br /> 11. Transporter 2:Acknowledgement of Receipt of Materials <br /> I l <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 _A Number/US EPA ID Number k <br /> Signature Print Name Date <br />