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FROM FAX NO. :2092394919 Tun. 28 2004 09:58AM P2 <br /> GUIDELINES FOR THE MEDICAL WASTE MANAGEMENT PLAN <br /> (Please Type or Print) <br /> Small quantity generators that provide onsite treatment and all large quantity generators shall have a medical waste <br /> management plan on file with the local enforcement agency. Minimum required information: <br /> Business Name:_ (6CA P-e KM G ew iek <br /> Business Address: /p �� �� ,Lf_�4-fJ7G� 1• �� <br /> Business Phone: ,,,? <br /> Type Of Facility/Business: -- <br /> Registered As: (Check One) <br /> () Small Quantity Generator With Onsite Treatment.(Generates<200 lbsJmo.) <br /> () Large Quantity Generator,(Generates 2001bs.or more/mo.) <br /> (} Large Quantity Generator With Onsite Treatment.(Generates 200 tbs.or more/mo.) <br /> ( ) Common Storage Facility(Small Quantity Generators only.) <br /> Person Res onsible For Implementation Of The Pian:'N � P_/ <br /> Name: �7�11j /� � Title: V Phone: <br /> ATTACH THE FOLLOWING ADDITIONAL INFORMATION <br /> l, List the types of regulated medical waste generated at your facility(refer to list on page 2). <br /> 2. Estimate the monthly amount,in pounds,of medical waste generated at your facility. <br /> ;. Describe the medical waste handling procedures utilized by and applicable to your facility: <br /> a. Onsite location and method for segregation,containment,packaging, labelling,and collection. <br /> b. Storage area description with storage methods utilized, including duration and temperature <br /> controls, if applicable. <br /> C. Onsite treatment facility description, including type of treatment utilized, maximum capacity,time <br /> and temperature necessary,alternate contingency plan in case of equipment failure,etc. <br /> Name, address, registration number, and phone number, of the registered hazardous waste hauler <br /> employed by your facility, <br /> e. Name, address, and phone number of offsite treatment facility where medical waste is transported <br /> for treatment, if different than the hauler. <br /> f.. Do you have a Limited Quantity Hauling Exemption? Who on your staff is authorized to transport <br /> your medical waste? N 0 <br /> g. Do you have tracking documents for all medical wastes handled at your facility? All medical <br /> waste generators are required to keep accurate records regarding containment,storage,hauling, <br /> treatment and disposal. All medical waste records are to be maintained and available for 3 years. <br /> h. Describe your medical waste emergency action plan, including procedures for handling spills, <br /> exposures,equipment failures,etc. <br /> I hereby certify that to the st of my knowled a and belief that the statements made herein are correct and true_ <br /> SIGNATURE: TITLEJ� � "DATE: /�iO�f <br /> 5 <br /> I <br />