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Administration <br /> St.Joseph's Medical Center Safety&Emergency Management <br /> 1800 North California Street <br /> A (j 1W P.O.Box 213008 <br /> Stockton,CA 95213-9008 <br /> 209 4615221 Telephone <br /> 209 4613299 Fax <br /> At the end of the 6 months audit both Stericycle and SJMC came to the conclusion that the hospital did <br /> not meet the criteria for Pharmaceuticals waste to be classified as RCRA waste, in was determined that <br /> we did in fact have trace amounts only. <br /> Stericycle, SJMC's contracted provider for the removal/disposal of sharps, pathology waste, <br /> pharmaceuticals waste and trace chemo waste, monitors by volume and as well as conducts random <br /> container inspections. Stericycle is not licensed to transport RCRA waste and as such they have <br /> processes in place to ensure that they are not transporting anything over trace amount of pharmaceutical <br /> waste. The Stericycle technician's are on-site every Tuesday and Wednesday to evaluate, remove, <br /> manifest, transport and dispose of SJMC's RWM, Non-RCRA pharmaceuticals waste, trace chemo waste <br /> and sharps. <br /> In response to your noted violation on February 25, 2011 the following has been implemented. <br /> • A communication plan has been developed and sent out to all departments within the hospital <br /> that receive/distribute medications. The communication plan states that any and all potential <br /> RCRA waste be sent back to the main hospital pharmacy. <br /> • The hospital pharmacy staff has been given separate waste container for all/any potential RCRA <br /> waste that is returned to the pharmacy from the nursing units. The pharmacy staff will then <br /> determine if the waste should be treated as trace or RCRA. <br /> SJMC will monitor the volume of RCRA waste that is returned from the nursing units for the next 90 days, <br /> March 151—June 1 st, 2011 to determine if a change in process/program is needed in order to maintain <br /> compliance. To the extent RCRA waste is collected it will be hauled by a licensed RCRA hauler. <br /> Item 20 <br /> Violation: The following hazardous waste containers had incomplete labeling; <br /> A. 55 gallon poly drum with glycerol /magnesium dichloride located in the storage area was missing the <br /> hazardous properties. <br /> Corrective Action: The 55 gallon drum of glycerol/magnesium dichloride has been labeled properly with <br /> missing name and address of the generator, hazardous properties, waste composition, physical state and <br /> accumulation date. <br /> b. 1-gallon container in the clinical lab was missing the name and address of the generator, hazardous <br /> properties, composition and physical state. <br /> Corrective Action: Container has been properly was labeled with missing name and address of the <br /> generator, hazardous properties, waste composition, physical state and accumulation date. <br /> c. Three 55 gallon drums of used oil in the storage area were missing the hazardous properties. <br />